Health History Form
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Personal Info
First Name
Last Name
Pronouns
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
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
Kosovo
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
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
ONLY COMPLETE RELEVANT SECTIONS
Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low 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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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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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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Sacrum
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Tailbone (coccyx)
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Which best describes what you are experiencing
Pain
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Ache
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Tension
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Mild
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Moderate
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Getting Worse
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Disabling
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Staying the Same
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Discomfort
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Getting Better
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Treatment Goals
Pain Relief
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Stress Relief
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Support in Healing/Recovery
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Rehabilitation
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Health Advice for Healing
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Improve Well Being
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Improve Symptoms
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Improve Lifestyle
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Other
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Well Being
Flexibility
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Range of Motion
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Hobbies
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Exercise
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Sports
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Interests
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Drinking
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Caffeine
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Smoking
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Mobility/Walking Aids
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Energy
When is your energy highest?
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When is your energy lowest?
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Is your energy constant?
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How long do you sleep on average?
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Do you struggle with insomnia?
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Headaches
Migraines
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Chronic Daily Headache
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Regular Headache Occurrence
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Tension
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Cluster
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Other Headaches
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Brain Disorders
Panic Disorder
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Acute Stress Disorder
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Bipolar Disorder
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PTSD
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Agoraphobia
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Borderline Personality Disorder
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Schizophrenia
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Anorexia Nervosa
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Bulimia Nervosa
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Claustrophobia
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Sleep Disorder
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Antisocial Personality Disorder
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Depression
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Social Anxiety Disorder
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ADD
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Generalized Anxiety Disorder
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ADHD
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Obsessive Compulsive Disorder
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Autism Spectrum Disorder
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Obsessive Compulsive Personality Disorder
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Energy Level
Low
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Clear
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Even
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Chaotic
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Fatigue
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Agitated
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Dull
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Flat
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Vibrant
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High
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Oncology (CANCER PATIENTS ONLY)
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Mouth Sores
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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Cardiovascular
Blood Clots
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Atherosclerosis
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Fainting Spells
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Heart Attack
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Raynaud Disease
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Postural Orthostatic Tachycardia Syndrome
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Swelling
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Blood Pressure
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Lymphedema
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Cardiac Arrhythmia
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Phlebitis
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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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Cold Hands
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Chronic Venous Insufficiency
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Cardiovascular Accident
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Peripheral Vascular Disease
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Cold Feet
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Congenital Heart Defect
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Pacemaker
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Acute Coronary Syndrome
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Chest Pain
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High Blood Pressure
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Coronary Artery Disease
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Heart Disease
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Myocardial infarction
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Aneurysm
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Heart Condition
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Low Blood Pressure
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Hyperlipidemia
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Varicose Veins
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Angina
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Stroke
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Congestive Heart Failure
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Cardiovascular Conditions
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Pericarditis
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Other Cardiovascular
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Blood
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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Blood Thinner Medication
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Stroke
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High Cholesterol
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Fainting Spells
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Anemia
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Bleeding Disorder
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HIV/AIDS
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Hypercoagulability
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Other Blood
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Respiratory
Chronic Cough
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Respiratory Conditions
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Shortness of Breath
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Asthma
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Tuberculosis
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Sinus Problem
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Emphysema
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Respiratory Tract Infection
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Bronchitis
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COPD
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Cystic Fibrosis
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Infectious Respiratory Conditions
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Other Respiratory
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Emotion / Memory
Stress
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Alzheimer Disease
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Anxiety Disorder
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Mood Disorder
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Schizophrenia
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Substance Use Disorder
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Reproductive
Endometriosis
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Menopause
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Pelvic Inflammatory Disease
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Pregnancy
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Premenstrual Syndrome
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Ectopic Pregnancy
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Gynaecological Conditions
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Ovarian Cysts/Tumors
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Breast Disorder
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Other Reproductive
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Prenatal (current only)
Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Sacral Injury
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Tailbone Injury
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Musculoskeletal
Bone Disease
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Baker's Cyst
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Paget Disease
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Ehlers-Danlos Syndrome
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Broken Bone / Fracture
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Compartment Syndrome
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Chronic Myofascial Pain Syndrome
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Osteoarthritis
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Recti Diastasis
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Psoriatic Arthritis
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Bone or Joint Disease
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Osteoporosis
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Plantar Fasciitis
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Dislocation
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Chronic Fatigue Syndrome
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Scleroderma
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Joint Stiffness / Swelling
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Temporomandibular Joint Dysfunction
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Dupuytren's Contracture
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Tendonitis/Bursitis
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Sinus Problems
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Fracture
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Scoliosis
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Spasms / Cramps
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Gout
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Artificial Joints / Special Equipment
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Whiplash
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Hereditary/Congenital Deformity
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Strain/Sprain
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Joint Injury
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Spondylolisthesis
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Amyotrophic Lateral Sclerosis (ALS)
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Degenerative Disk Disease
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Carpal Tunnel Syndrome
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Fibromyalgia
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Osgood-Schlatter Disease
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Muscular Dystrophy
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Arthritis
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Jaw Pain (TMJD)
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Ankylosing Spondylitis
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Torticollis
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Osteomalacia
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Myasthenia Gravis
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Other Musculoskeletal
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Neurological
Cerebral-vascular Accident
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Stabbing
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Vertebral and Spinal Cord Injury
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Sleeping Disorders
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Loss of Sensation
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Huntington Disease
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Sciatic Pain
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Carpal Tunnel
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Stroke
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Brain Disorder
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Chiari Malformation
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Chronic Pain Disorder
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Bell's Palsy
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Cerebral Palsy
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Syringomyelia
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Epilepsy
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Fibromyalgia
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Brain Injury
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Peripheral Neuropathy
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Parkinsons
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Numbness
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Tethered Cord
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Shingles / Herpes
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Shingles
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Cerebral Vascular Accident (Stroke)
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Herniated Disc
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Burning
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Cerebrospinal Fluid Leak
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Twitching of Face
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Dizziness
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Seizure Disorder
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Transient Ischemic Attacks (TIA)
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Post Polio Syndrome
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Multiple Sclerosis
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Tingling
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Dural Ectasia
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Fatigue
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Other Neurological
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Endocrine
Hyperthyroidism
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Temiskaming Diabetes Program
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Hypothyroidism
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Blood Sugar Managed?
Characters:
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Pituitary and Growth Disorder
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Diabetes
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Wound Healing Status?
Characters:
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Prostate Condition
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Adrenal Fatigue
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Acute Pancreatitis
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Other Endocrine
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Hearing
Vertigo
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Ear Problems
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Conductive Hearing Loss
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Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Other Hearing
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Gastrointestinal
Crohn's Disease
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Esophageal Disorder
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Abdominal Hernia
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Fecal Impaction
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Gastroparesis
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Acid Reflux
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Intestinal Polyps
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Celiac Disease
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Hiatal Hernia
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Irritable Bowel Syndrome
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Constipation
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Stomach Disorders
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Poor Appetite
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Diarrhea
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Intestinal Gas/Bloating
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Stomach Disorder
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Diverticulitis
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Adaptive Aids
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Ulcerative Colitis
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Eating Disorder
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Digestive Conditions
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Other Gastrointestinal
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Immune
Hodgkin Lymphoma
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CVID
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Infectious Mononucleosis
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Rheumatoid Arthritis
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Leukemia
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Anaphylaxis
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Allergies
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Non-Hodgkin Lymphoma
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Lupus
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Cancer
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Sjogren's Syndrome
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HIV/Aids
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Other Immune
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Kidney
Chronic Kidney Disease
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Congenital Kidney Disease
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Electrolyte Imbalance
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Kidney Stones
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Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Other Kidney
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Skin
Athlete's Foot
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Allergic Dermatosis
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Rash
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Hypersensitive Reaction
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Athletes Foot
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Bruise Easily
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Rosacea
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Herpes
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Chemical Burn
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Eczema
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UV Burn
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Severe Irritability
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Melanoma
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Hypersensitive Reactions
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Non-Surgical Scars
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Melanoma/Carcinoma
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Surgical Scars
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Pigmentary Disorder
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Plantar's Wart
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Skin Conditions
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Infectious Skin Conditions
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Acne
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Psoriasis
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Skin Irritations
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Sensitive Skin
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Other Skin
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Feet
Itchy or Peeling Skin
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Plantar Fasciitis
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Dry/Cracked Skin
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Heel Fissures
Characters:
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Onychoptosis (Nail Loss)
Characters:
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Previous Amputations
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Onychomycosis (Nail Fungus)
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Pes Planus (Flat Feet)
Characters:
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Pes Cavus (High Arch)
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Involuted Nails (Curved/Pinched)
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Thickened Nails
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Yellow Nails
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Bunions
Characters:
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TMJ (Jaw)
Difficulty Chewing
Characters:
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Clenching
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Jaw Pain
Characters:
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Grinding
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Clicking
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Locking
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Difficulty Opening Jaw
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Emotion / Mood
Rate the stress in your life (1-10)
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Depression
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Grief
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Physical Abuse History
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Mental Abuse History
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Negative Self-Talk
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Confusion
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Anger
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Anxiety
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PTSD
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Fear
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Sadness
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Other Emotions
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Stress Response and Coping Strategies
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Overall mood and energy level
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Family History
Cancer
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Arthritis
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Diabetes
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Cardiovascular
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Respiratory
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Miscellaneous
Contact Lens
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Vision Problems
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Liver Disease
Characters:
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Vision Loss
Characters:
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Surgical Pins or Wire
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Hearing Impaired
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Visually Impaired
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Loss of Balance
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Weakened Immune Function
Characters:
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Other Medical Conditions
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Other Diagnosed Diseases
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