Health History Form

Health And Well Being History Form

Name
Address
Home Phone
Cellular Phone
Date
PART 1.
* Please answer the following questions honestly and to the best of your ability.
Describe the problem(s) for which you seek help. Please include dates when each problem occurred:
Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates
List the medications (including over the counter) you are presently taking
What daily activities are you finding difficult or are limited because of your above complaints
Have you ever had this problem before, and if so when
What are your goals from BodyTalk
Please list any other kind of healthcare professional you are seeing for this/these problem(s)
Please list any medical tests you have had within the past year
* Please circle any of the following feelings you have experienced in the last few months.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
My family stress is        
My relationship stress is        
My work stress is        
My financial stress is        
My health stress is        
Other stress is        
How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc ?
PART 2.
* Please list areas of pain and mark the circle that best describe the level of discomfort on a scale of 1 to 10.
1. Slight awareness of discomfort.
2-3. Awareness of discomfort as an aggravation.
4-6. Pain is strong but you are still functional.
7-9. Pain is so strong you are unable to function normally.
10. You feel like you need to go to the emergency room.
Pain Area
Level of Discomfort
Pain Area
Level of Discomfort
Pain Area
Level of Discomfort
Pain Area
Level of Discomfort
Do you exercise? And if so, what kind and how often?
How many hours a night do you sleep?
Is your sleep restful?
f not, please explain:
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