NATUROPATHIC HEALTH HISTORY FORM

Name Date

In order to ensure safe and optimum care, your naturopathic doctor requires the following information. This information will be kept strictly confidential.

PAST MEDICAL HISTORY: Do you suffer from or have you ever been told you have the following conditions and/or diseases? Please check all applicable

SKIN: GASTROINTESTINAL: NEUROLOGICAL: Rashes, hives, itchiness Heartburn/acid reflux Fainting/loss of consciousness Moles/warts Trouble swallowing Seizures/convulsions Dry, flaking skin or scalp Changes to appetite/thirst Speech problems/slurring Oily skin Belching/burping Loss of sensation Hair changes (colour/loss) Gas Numbness/tingling Oily or dry hair Bad breath/bad taste in mouth Paralysis Eczema/psoriasis Bloating/abdominal pain Twitching Acne Nausea/vomiting Tremors Night sweats Blood or mucous in stool Significant memory loss Skin infections Black tarry stool Vertigo Rectal bleeding/hemorrhoids HEAD/NECK: Diarrhea BLOOD & LYMPHATIC: Head injury Constipation Anemia Issues with Jaw/TMJ Ulcers Easy bruising/bleeding Dizziness or Light-headedness Gallbladder stones/removal Blood transfusions Swollen glands/lymph nodes in neck Hernia Lymph node swelling Thyroid concerns Hemophilia/clotting problems Pain/stiffness in neck PERIPHERAL VASCULAR: Headaches or migraines Cold hands/feet BLOOD TYPE, IF KNOWN: Ankle/leg swelling A EAR, NOSE & THROAT: Varicose/spider veins B Frequent colds Painful veins AB Allergies/hay fever Deep leg pain/cramps O Sinus problems/infection Weakness in limbs Congestion Phlebitis MUSCULOSKELETAL: Nosebleeds Joint pain/stiffness Frequent sore throat ENDOCRINE: Bone fractures Hoarseness Sensitivity to heat/cold Sciatica Sore or dry tongue/mouth Thyroid problems Muscle weakness Gum disease/bleeding Excessive hunger/thirst Muscle spasms/cramps Cold sores Steroid therapy/use Leg cramping History of ear infections Hormone replacement therapy Back pain Hearing loss Excessive urination/sweating Arthritis Osteoporosis Ringing in ears Low blood sugar/hypoglycemia Diabetes WOMEN: RESPIRATORY: Weight gain Pregnancy Chronic cough Weight loss Shortness of breath Irregular periods Bronchitis Premenstrual symptoms URINARY SYSTEM: Asthma Menopausal concerns Pain/burning with urination Emphysema Incontinence OTHER: Urinary tract infections CARDIOVASCULAR: Hepatitis Blood in urine High blood pressure HIV Low blood pressure Urgency/hesitancy Tuberculosis Irregular heart beat/rate Kidney problems/disease Cancer Chest pain or angina Kidney stones/infection Injuries or hospitalizations Heart disease History of heart attack Pacemaker Stroke/CVA NATUROPATHIC HEALTH HISTORY FORM

Previous Surgeries Yes No Current Medications Yes No

Date Name

Type For what condition

Previous Injuries Yes No Current Supplements Yes No

Date Name

Type For what condition

Have you had any of the following tests done recently or previously?

X-ray Bone scan Colonoscopy CT scan Blood work Pap smear MRI Urinalysis Breast exam/mammography EMG Fecal occult blood test

Please state when and where

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