Your Health History Name * First Name Last Name Birth Date MM DD YYYY Email * Phone * (###) ### #### Address * City Province Postal Code What is you occupation? Are you presently experiencing any of the following ? Pain Skin Rash Cold/Flu Inflammation Headache Cuts, Bruises, Burns Decreased Range of Motion Broken bone How would you describe your daily energy level? * low energy (frequnetly fatigued, at times feeling listless) normal energy (focused, handle tasks with ease through out the day) high energy (feel nervous, overly excited, cant sit still) Are you undergoing any other therapies? * Yes No if yes, please list them. When did you last see your Dr? * In the last month 2-6 months ago 6months to a 1 year ago Other reason for seeing your Doctor List past injuries and/or surgeries. Are you taking any medication (including vitamins, dietary supplements)? * Yes No if yes, please list them and for what reason. Do you sleep well? * Yes No if no, explain. Do you suffer from anxiety or worry? * Yes No if yes, please explain. Is your blood pressure: * Normal High Low Erratic Are you pregnant * Yes No Does not apply if yes, what trimester? 1st 2nd 3rd Have you had other pregnancies? Yes No Does not apply if yes, were there complications? (please explain) Do you have allergies * Yes No if yes please list them. Do you have or wear any of the following? glasses/contacts artificial limb/joint metal plate pins or wires dentures hearing aid Indicate your Consumption/Activity level of the following : Salt none light moderate heavy Sugar none light moderate heavy Caffeine none light moderate heavy Marijuana/CBD none light moderate heavy Tobacco none light moderate heavy Alcohol none light moderate heavy Water none light moderate heavy Exercise none light moderate heavy Do you have problems with any of the following systems? Endocrine System (diabetes, hypoglycemia, menopausal problems, hypothyroidism) Yes No Urinary System (kidney disease, urinary problems) Yes No Cardiovascular (high/low blood pressure, heart disease, phlebitis, varicose veins, circulation problems, anemia) Yes No Immune & Lymphatic (arthritis, chronic fatigue, environmental illness, HIV/AIDS, allergies) Yes No Musculoskeletal (osteoporosis, fibromyalgia, bursitis, gout, back pain, scoliosis, foot -arm or hand problems) Yes No Respiratory (asthmas, emphysema, breathing issues) Yes No Nervous System (vision, hearing loss/problems, loss of sensation, nerve pain/damage, mental or emotional problems, MS) Yes No Reproductive (PMS, dysmenorrhea, endometriosis, prostate problems) Yes No Digestive (prolonged constipation, diarrhea, Crohn’s Disease, Colitis, diverticulitis, ulcer) Yes No Is there anything else about your health you would like to discuss? Thank you for filling out your Health Record. See you soon.