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CENTER FOR NATURAL HEALTH
HEALTH INFORMATION FORM
NAME___________________________________ HOME ADDRESS_________________________ CITY, STATE, ZIP_________________________ HOME TELEPHONE_______________________ CELL PHONE_____________________________ DATE OF FIRST APPOINTMENT____________ DATE OF BIRTH______________AGE________ WEIGHT_____________HEIGHT_____________ OCCUPATION____________________________ WORK TELEPHONE_______________________ PERSONAL MEDICAL DOCTOR____________ ADDRESS________________________________ E-Mail Address_____________________________ Blood Type__________________ 1)________________________________________ 2)________________________________________ 3)________________________________________ 4)________________________________________ 5)________________________________________ _________________________________________ Are you interested in being on our mailing list for programs & workshops? HEALTH HISTORY

LIST ALL SURGERIES YOU HAVE HAD: _______________________________________
______________________________________________________________________________
LIST ALL CHILDHOOD ILLNESSES: ___________________________________________
LIST ALL HOSPITALIZATIONS:________________________________________________
______________________________________________________________________________
LIST ALL ACCIDENTS AND INJURIES__________________________________________
______________________________________________________________________________
LIST ALL AREAS OF PAIN (experienced in the past four months): ___________________
______________________________________________________________________________
LIST ALL DIAGNOSED OR SUSPECTED ILLNESSES, DISEASES AND HEALTH
PROBLEMS___________________________________________________________________
______________________________________________________________________________
LIST ALL KNOWN ALLERGIES________________________________________________

ALLERGIES TO MEDICATIONS_________________________________________
LIST METHOD OF BIRTH CONTROL (IF ANY):__________________________________
LIST ALL PRESCRIPTION MEDICATIONS TAKEN WITHIN THE PAST 12 MONTHS
______________________________________________________________________________
LIST ALL NON-PRESCRIPTION MEDICATIONS TAKEN WITHIN THE PAST 12 MONTHS
(ASPIRIN, HORMONES, LAXATIVES, ANTACIDS, TRANQUILIZERS, etc.)
______________________________________________________________________________
______________________________________________________________________________
LIST ALL VITAMINS, MINERALS, ENZYME, GLANDULAR OR HERB SUPPLE-MENTS
YOU HAVE RECENTLY TAKEN OR ARE NOW TAKING__________________
______________________________________________________________________________
______________________________________________________________________________
BRIEFLY DESCRIBE ANY DIETARY PROGRAM YOU ARE FOLLOWING: _________
______________________________________________________________________________
BRIEFLY DESCRIBE ANY EXERCISE PROGRAM YOU ARE FOLLOWING ON A
REGULAR BASIS: _____________________________________________________________
BRIEFLY IDENTIFY STRESS FACTORS , MAJOR OR MINOR, WHICH YOU ARE AWARE OF:

SOCIAL:____________________________________
FAMILY: _______________________________ SCHOOL OR WORK:_________________________
ENVIRONMENTAL: _____________________ OTHER: ________________________________
Briefly note diseases and surgeries experienced by your immediate family:
Age

Spouse:_______________________________________________________________________
Parents: Father:__________________________________________________________
Mother:__________________________________________________________
Sisters:________________________________________________________________________
Brothers:______________________________________________________________________
Children:______________________________________________________________________
WHEN WAS YOUR MOST RECENT EXAM BY A MEDICAL DOCTOR?_____________
DESCRIBE

DONE:________________________________________________
NOTE ANY RELIGIOUS OR PERSONAL BELIEFS RELEVANT TO HEALTH,
ILLNESS OR TREATMENT METHODS (IF ANY):__________________________
LIFESTYLE:
Cigarettes________pack/day

caffeine_______drinks/day alcohol______drinks/day
Recreational drugs_____________ Meditation/Relaxation______________________
Sugar________________/day Water_____________________/day
******************

SYMPTOMS SURVEY I
If you have had any of these symptoms within the past year, check the box
next to them:
ο Coughed up blood or vomited blood.
ο
Noticed black or bloody stool, brown black or bloody urine.
Noticed a yellowing in the whites of your eyes.
o Have had a nagging cough, hoarseness, or a sore throat that did
not heal within 10 days.
Have had a breast lump, or unexplained lump or cyst anywhere in the
body.

Have had unexplained thickening anywhere in the body.
Have experienced marked unexplained weight loss, shortness of breath
or any dramatic change in normal body functioning.

Have had a crushing pain in the center of your chest, that may have
been accompanied by pain radiating down the left arm, severe nausea,
clammy skin, difficulty breathing or an irregular heartbeat.

Have had a cut sore or lesion that hasn’t healed or an obvious
enlargement or change in warts and moles.

Have experienced unexplained rapid or irregular heartbeats.
Have experienced unexplained dizziness, blurring or distorted vision,
fainting spells or blackouts or prolonged fatigue or exhaustion.

Have experienced a blow to the head that caused unconsciousness.
Have had abdominal pain that lasts for 12 hours or more and is very
intense for several hours.

Have had an obvious blockage of the intestinal tract.
Have swallowed any dangerous, poisonous chemicals, drugs or highly
toxic substances.

Have been in an accident and suffered lacerations, serious abrasions,
broken bones, possible whiplash or other injuries known or suspected.

Have had a great tightness in the chest or great difficulty swallowing.
Have had an oral temperature over 102 degrees farenheit for more
than

Have a hernia.
Have taken prescription drug, Zelnorm.
Oversensitivity to drugs, herbs or supplements.
∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗∗
SYMPTOMS SURVEY II
If you are presently experiencing any of these symptoms, check the box next to them.
This survey provides health history information and considerations for your health
and healing program.
General Notes

general fatigue or weariness
wear glasses or contacts
shortness of breath with normal activities.
wear sunglasses
trembling
eyesight worsening
numbness
seeing double
dizziness
see halos or lights
lack of endurance
eye pains or itching
balance ο
watering eyes or dry eyes
memory ο
redness in eyes
hearing difficulties
weight ο
earaches
appetite ο
noises in ears
excessive
appetite
other notes:____________
difficulty sleeping
fever or chills
fainting Respiratory System
motion sickness
other notes:___________________________
congested nose
Number of bowel movements per day _____
sinus problems
Number of hours sleep per night _________
running nose
Quality of sleep per night________________
sneezing spells
Number of times you awaken to urinate____
head colds
How do you feel when you awaken? _______
chest colds
Do you live in peaceful surroundings?______
difficulty breathing deeply
nosebleeds
sore throat
difficulty swallowing
Rashes, flaking, itching, burning skin
hoarse voice
lesions, cysts, calluses, lumps
wheezing or gasping
cold/warm hands or feet
excessive mucous /phlegm
swelling edema. swollen feet or ankles
frequent coughing
excessive
perspiration ο
other notes:___________
Urinary System
cracked or chapped lips
frequent urination
problems ο
involuntary escape of urine
burning or discharge
cracking or discolored nails
weak urine stream
other notes____________________________
difficulty starting urine
constant urge to urinate
Other symptoms____________________________
bedwetting
other notes:___________
Cardiovascular System Endocrine
rapid or skipped heartbeats
swollen glands
varicose
swelling in armpits or groin
excessive thirst, hunger, urination
slow or fast metabolism
frequently colder than others
blood sugar imbalances
frequently warmer than others
night sweats
other notes:__________________
hot flashes
other notes:_________________
Neuromusculoskeletal System
ο
headaches: frequency____severity_____
Digestive System
neck or shoulder pain
recurring indigestion, heartburn
back or hip pain
flatulence or gas
arm or hand pain
nausea, vomiting
leg or foot pain
cramping in abdomen
cramping
bloated abdomen
weakness in arms or legs
constipation
diarrhea
stiffness
grey or whitish stools
other notes______________________
pain or itching in rectum
excessive appetite /lack of appetite
Dental System
other notes:________________
problems
sore or bleeding gums
Women Only
halitosis or bad breath
bleeding between periods
tension or pain before periods
vaginal discharge
jaw pain or tension
rash, irritation /pain in genital area
other notes:_____________________
pain on intercourse
swelling or soreness in breasts
burning or discharge on urination
age menstruation began:_______
lumps or swelling on testicles
age at menopause:____________
pain in prostrate or testicles
frequency of periods__________
ο impotence > amount of bleeding during periods:
other notes:_____________________
regular little excessive sporadic
____number of pregnancies ___cesareans
____miscarriages
___abortions
____premature births
____number of births

nervousness or anxiety
nail biting
difficulty making decisions ο
loss of memory
annoyed easily
lack of concentration
problems at work
depressed/moody
sought psychiatric help
considered suicide
angered easily
frightening dreams /thoughts ο
difficulty relaxing
worry a lot
change of sexual energy
sexual difficulties
hopeless outlook
feeling of desperation
frequent crying
shy or sensitive

Assessing Your Exposure Risk~

Your mother took prescription diethylstilbestrol (DES), the first
synthetic estrogen ever marketed, or another synthetic hormone when
she was pregnant with you?

You consume a diet low in animal fats ?
You consume nonorganic dairy products.
You have town chlorinated water.
You use hair coloring or permanent hair dye
You dry clean some clothes.
You eat nonorganic, commercially grown foods.
You eat canned foods and drinks.
You microwave food in plastic containers or cover foods with plastic
cling wrap.
You use pesticides on your lawn and garden or bombs in your home.
You use sun screens and insect repellent on your skin.
Your pets wear flea collars.
You use regular washing detergent.
You use air fresheners in your home or car or deodorizers in your
bathroom.
You use solvents or chemicals in your work, home or hobbies or have
been exposed to them in the past.
You use synthetic sweeteners such as nutri-sweet, aspartame, etc. o
You drink diet soda, regular soda or sport drinks
Served in the military in Vietnam.
Had a blood transfusion before 1992.
You have been exposed to chemicals other than those listed above.
Explain:____________________________________________________
___________________________________________________________

Source: http://centerfornaturalhealth.com/CNH%20Health%20Information%20Form.pdf

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