Laurapower.com

HEALTH HISTORY
Name______________________________________________________________Date_________________Phones: (W)_________________(H)_________________(Fax)_______________(email)_____________________Address__________________________________________________________________ Zip_______________Referred by ___________________________________For___________________________________________Insurance__________________________________Hosp. only_____HMO_____PPO_____PPO+_____Full_____ VITAL STATISTICS
Date of Birth________________ Age________ Height_________ Weight__________ Desired Weight___________Gender ________ Blood Type_________ Race__________Ethnic Ancestry_______________________________Age of Puberty ________ # Children ________ Menstrual Cycle: # days ____________ Menopause Age _________ PURPOSE OF VISIT
Primary ____________________________________________________________________________________Secondary _________________________________________________________________________________ MEDICAL HISTORY
Infancy: Premature?________Breastfed? _______ How long? __________ Formula: Cow ____ Goat _____ Soy _____Childhood Diseases___________________________________________________________________________Teenage Diseases____________________________________________________________________________Adult Diseases________________________________________________________________________________________________________________________________________________________________________Family Diseases______________________________________________________________________________Injuries____________________________________________________________________________________Surgeries_____________________________________________________Complications___________________Allergies___________________________________________________________________________________Current Medications __________________________________________________________________________Past Medications_____________________________________________________________________________Primary Physician _________________________Diagnosis____________________________________________ Specialist Physician ________________________Diagnosis___________________________________________Other Therapists_____________________________________________________________________________ LIFESTYLE
Occupation_____________________________________________________________Long Hours?__________Major Life Stresses___________________________________________________________________________Travel Frequently____________________________Eat At Restaurants Frequently __________________________Exercise__________________________________________________________ Hours Per Week? ___________Sleep: Hours at Night__________Dreams About Health_____________________Nightmares__________________Fatigued-Drowsy?__________Daily Energy Peaks__________________Daily Energy Lows____________________Glasses_____Contact Lenses______ Strength ____________Tint_____________Eye Surgery________________Dental Disease or Surgery _____________________________________________Dentures__________________Water Source: Tap ________ Well ________ Filtered ________ Bottled ________Type Plumbing?_______________Drink Alcohol? _________ How Much? ______________________ How many years? ________Quit?____________ ____ Child -- Poor growth, short____ Teen -- Delayed puberty ____ Sodas, Alcohol, Cortisone, Diuretics DIET PATTERNS
DIGESTION
ALLERGY SYMPTOMS
____Sensitivity to light or soundMusculo-Skeletal FOODS EATEN
AMINO ACIDS
FATTY ACIDS
SACCHARIDES

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