The Full Story
Name: ____________________________________________ Date: _____________________________
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: _________
Name: __________________________________________ Relationship: ________________________
Phone: (Home) _________________ (Work) ___________________ (Cell) ________________________
OTHER HEALTH CARE PROVIDERS (family doctors, specialists, complimentary health care providers):
When was your last physical exam? ________________________________________________________
When was your last blood work done? _____________________________________________________
CURRENT HEALTH CONCERNS (in order of importance):
PERSONAL AND FAMILY MEDICAL HISTORY
Are you or any member of your immediate family experiencing (or have experienced) the following conditions:
Which family member?
Which family member?
Cancer (specify type)
High blood pressure
Mental illness (please specify)
Thyroid disease (hyper/hypo)
___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:
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:
Please list any supplements you are currently taking:
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? ______________________________