Name * First Name Last Name Date of Initial Consult * MM DD YYYY Office Visit * Select Yes No Virtual Session * Select Yes No Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Referred by Phone * Country (###) ### #### Date of Birth * MM DD YYYY Occupation Marital Status * Select Married Divorced Single Widow Have you ever used naturpathic/holistic/alternative or complementary medicine to heal? Select Yes No Describe briefly objective, expecations and actual results. * What is your chief complaint (concern)? * Lifestyle: Diet/Nutrition * Exercise * Check Below Tobacco Alcohol Drugs (non RX) Herbal Supplements None Other Hours of Sleep * Select 1 2 3 4 5 6 7 8 9 10 11 12+ Number of Bowel Movements daily * 1 2 3+ Caffeine * Select Yes No Recreational Activities * Medical History * Hypertension PMS/painful menstruation Osteoporosis Heart Disease Arteriosclerosis Easy bruising Skin Rash Osteoarthritis Rheumatoid Arthritis Varicose Veins Abscees or open sore Fibrositis Phlebitis Fluid Retention Epilepsy Headaches Skin Sensitivity Allergies Herpes 1 or 2 HIV Positive Fibromyalgia Diabetes Herniated Disc Cancer/ Malignancy Other Infectious Diseases Sex * Select Male Female Rather not Specify Women * Pregnancies Viable/Live Births Miscarriage/Abortions Age at onset Menses Last Menstrual Period Intrauterine Device Age at onset Menopause History of mental Illness Are you taking any medication? If so, what and what for? * Surgery/Fractures (explain) (Dates): * Prior Injuries (explain) (dates) * Any Counseling History: * Select Yes No Any history of abuse (recent or past verbal ,physical, sexual, or emotional): Select Yes No Any recent lifestyle/emotional challenge or loss * Select Yes No Are you under the care of a physician or other medical practitioner now * Select Yes No If Yes conditions being treated * Do we have your permission to contact your physician should the need arise? Select Yes No Thank you! Personal Data and Health Screen Personal Data and Health Screen Personal Data and Health Screen