HOW Health History Intake Form
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
General Health
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Primary Complaint
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
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Surgeries
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Please list any pins, wires, staples and/or prosthetics
Conditions
Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Musculoskeletal
Hereditary/Congenital Deformity
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Strain/Sprain
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Osteoporosis
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Osgood-Schlatter Disease
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Osteoarthritis
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Muscular Dystrophy
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Myasthenia Gravis
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Gout
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Ankylosing Spondylitis
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Osteomalacia
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Tendonitis/Bursitis
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Bone Disease
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Sinus Problems
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Paget Disease
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Psoriatic Arthritis
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Dislocation
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Fibromyalgia
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Scleroderma
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Arthritis
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Jaw Pain (TMJD)
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Fracture
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Scoliosis
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Cardiovascular
Varicose Veins
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Congenital Heart Defect
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History of Heart Attack
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Blood Pressure
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Blood Clots
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Acute Coronary Syndrome
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Coronary Artery Disease
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Phlebitis
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Lymphedema
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Aneurysm
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Hyperlipidemia
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Cardiovascular Accident
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Angina
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Pericarditis
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Pacemaker
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Atherosclerosis
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Cold Hands
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Raynaud Disease
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Heart Disease
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Cardiac Arrhythmia
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High Blood Pressure
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Low Blood Pressure
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Cold Feet
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Rheumatic Heart Disease
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Chronic Ischemic Heart Disease
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Valve Disorders
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Myocardial infarction
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Chronic Venous Insufficiency
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Congestive Heart Failure
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Neurological
Tingling
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Brain Injury
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Multiple Sclerosis
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Stabbing
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Cerebral Vascular Accident (Stroke)
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Cerebral-vascular Accident
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Loss of Sensation
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Seizure Disorder
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Sciatic Pain
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Stroke
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Transient Ischemic Attacks (TIA)
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Vertebral and Spinal Cord Injury
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Huntington Disease
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Epilepsy
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Shingles
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Cerebral Palsy
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Brain Disorder
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Dizziness
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Parkinsons
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Numbness
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Burning
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Chronic Pain Disorder
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Herniated Disc
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Headaches
Headaches
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Tension Headache
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Chronic Daily Headache
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Migraines
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Sinus Problems
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Other types
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Mental Health
Stress
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Anxiety Disorder
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Substance Use Disorder
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Mood Disorder
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Alzheimer Disease
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Schizophrenia
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Other Diagnosed Conditions
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Skin
Psoriasis
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Athlete's Foot
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Acne
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Rash
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Allergic Dermatosis
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Bruise Easily
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Rosacea
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Herpes
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Hypersensitive Reaction
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Athletes Foot
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UV Burn
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Chemical Burn
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Melanoma
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Hypersensitive Reactions
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Melanoma/Carcinoma
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Skin Conditions
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Infectious Skin Conditions
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Pigmentary Disorder
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Plantar's Wart
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Skin Irritations
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Ear Problems
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Vertigo
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Hearing Loss
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Blood
Hypercoagulability
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Hepatitis
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Polycythemia
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Haemophilia
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HIV
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Thrombosis/Embolism
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Anemia
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High Cholesterol
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Bleeding Disorder
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HIV/AIDS
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Gastrointestinal
Digestive Conditions
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Constipation
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Poor Appetite
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Diarrhea
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Crohn's Disease
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Stomach Disorder
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Diverticulitis
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Ulcerative Colitis
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Eating Disorder
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Esophageal Disorder
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Fecal Impaction
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Celiac Disease
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Intestinal Polyps
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Irritable Bowel Syndrome
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Kidney
Frequent Urination
Urinary Tract Infection
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Urinary Incontinence
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Renal Cysts
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Kidney Stones
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Bladder Disorder
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Congenital Kidney Disease
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Chronic Kidney Disease
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Electrolyte Imbalance
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Digestion
Trouble swallowing
Throat clearing
Nausea
Constipation
Diarrhea
Elimination Regularity (frequency)
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Reproductive
Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Breast Disorder
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Gynaecological Conditions
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Uterine Disorder
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Ectopic Pregnancy
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Endometriosis
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Menopause
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Pregnant
Yes
No
If pregnant, due date?
Number of pregnancies
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Number of live births?
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Women's Cycle
Type of Period
Light
Medium
Heavy
Spotting
Pediatric
When is the baby's date of birth?
What is your baby experiencing?
Feeding difficulties/latching
Constipation
Torticollis
Reflux
Colic
Tongue Tie
Birth trauma
Milestone development
Postural concerns
TMJ
Other
Is there anything else we should know?
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Immune
Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Anaphylaxis
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Allergies
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Lupus
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Hodgkin Lymphoma
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Cancer
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Infectious Mononucleosis
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Leukemia
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Respiratory
Chronic Cough
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Shortness of Breath
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Asthma
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Tuberculosis
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Emphysema
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Bronchitis
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Respiratory Tract Infection
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Chronic obstructive pulmonary disease (COPD)
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Cystic Fibrosis
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Endocrine
Acute Pancreatitis
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Pituitary and Growth Disorder
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Prostate Condition
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Cancer
Other
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Sleep
Insomnia
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Do you use a CPAP?
Yes
No
Do you have trouble sleeping?
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Is there anything else we should know?
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