GENERAL INFORMATION
Name:  ____________________________________________  Date:  _____________________________
Address: __________________________________________
City: _________________________ Province:  ______________ Postal Code: _____________________
Email address: _________________________________________________________________________
Phone: (Home) _________________ (Work) ___________________ (Cell) _________________________
Age: __________  Date of birth (month/day/year): ________________________  Gender:  ____________
Marital status:  __Single  __ Married  __ Partnership __ Common law  __ Separated __ Divorced  __ Widowed 
Name of Spouse: __________________________ Number of children: _________

EMERGENCY CONTACT
Name: __________________________________________  Relationship: ________________________
Phone: (Home) _________________ (Work) ___________________ (Cell) ________________________
Address: _____________________________________________________________________________

OTHER HEALTH CARE PROVIDERS (family doctors, specialists, complimentary health care providers):

Name

Role

Phone number

Address

 

 

 

When was your last physical exam? ________________________________________________________
When was your last blood work done? _____________________________________________________

CURRENT HEALTH CONCERNS (in order of importance):
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________

PERSONAL AND FAMILY MEDICAL HISTORY
Are you or any member of your immediate family experiencing (or have experienced) the following conditions:

Condition

Which family member?

Condition

Which family member?

Alcoholism/drug addiction

 

Allergies 

 

Anemia

 

Arthritis 

 

Asthma

 

Autoimmune disease

 

Cancer (specify type)

 

Crohn’s/Colitis

 

Diabetes 

 

Digestive concerns 

 

Epilepsy 

 

Headaches 

 

Heart disease 

 

Hepatitis 

 

High blood pressure 

 

Kidney disease 

 

Mental illness (please specify)

 

Osteoporosis 

 

Skin conditions 

 

Stroke 

 

Thyroid disease (hyper/hypo)

 

Tuberculosis 

 

Others:

 

___I don’t know my family medical history

What hospitalizations, injuries, or surgeries have you had?  When did they occur? ______________________________________________________________________________________________________________________________________________________________________________

What was your general state of health as a:
Child ___________________________________________________________________________________
Teenager ________________________________________________________________________________
Adult ___________________________________________________________________________________

 

ALLERGIES
List any allergies that you currently have or have had in the past (environment, food, drugs, other):
_____________________________________________________________________________________
Are you exposed to toxic chemicals at work or home on a regular basis?  _____________________________
Have you ever been exposed to heavy metals such as lead, arsenic, or mercury? ________________________

MEDICATIONS AND SUPPLEMENTS
Please list any medications you are currently taking, either prescribed or over the counter:  

Medication

Reason

Amount

How long

 

 

 

 

 

 

Please list any supplements you are currently taking:

Supplement

Reason

Amount

How long

 

 

 

 

 

How many times have you been on antibiotics in the past 10 years? __________________________________

GENERAL AND LIFESTYLE

How much alcohol do you consume per week?

How much caffeine do you consume per week?

How much tobacco do you consume per week?

How much cannabis do you consume per week?

How much water do you consumer per day?

How much exercise do you get per week?

              What kind of exercise do you do?

How would you describe the emotional climate of your home?

How would you rate your stress on a scale of 1-10 (10=worst)

How would you rate your energy on a scale of 1-10 (10=best)

Current height and weight: 

Is there anything else you feel is important that has not been covered?  ______________________________
_________________________________________________________________________________________