Health History Form

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Symptoms

Do you now or have you ever had any problems related to the following? Check all that apply. Gastrointestinal:

Heartburn/Acid Reflux

Change in Appetite

Irritable Bowel

Abdominal Pain

Constipation

Nausea

Blood in Stool

Diarrhea

Vomiting

Other

Symptoms

Do you now or have you ever had any problems related to the following? Check all that apply. General Skin/Body:

Chills

Dry Skin

Fever

Hair Loss

Rash

Skin Ulcers/Cellulitis

Skin Fold Infections/Irritations

Symptoms

Do you now or have you ever had any problems related to the following? Check all that apply. Psychiatric:

ADD/ADHD/OCD

Alcohol Abuse

Anxiety/Panic Issues

Bipolar Disorder

Depression

Drug Abuse

Eating Disorder

Sexual Abuse

Other

Hormonal

Do you now or have you ever had any problems related to the following? Check all that apply. Hormonal

Fatigue/Burned-Out Feeling

Abnormal/Unexplained Weight Gain

Foggy Thinking/Decreased Mental Sharpness

Lack of Motivation

Irritability/Anger/Mood Swings

Hot Flashes

Loss of Sleep

Decreased Muscle Mass/Inability to Gain Muscle

Decreased Stamina

Infertility Problems

Chronic Illness

Headaches/Aches/Pains