Alternative Health Associates

Alternative Health Services and Programs

About Us

Health History Assessment

Please fill out this form as completely as possible. It is detailed, please be honest.

Name: Age: Date: 08-Sep-10

I was recommended by:

Occupation: Hours spent working per week:

Weight: Your ideal weight: Height:

Blood pressure: Pulse/heart rate: PH: Temperature:

Your current medical doctor address/phone:

Last medical visit:

What kind of health test have you had in the past 1-2 years?:

Could you obtain a copy of any current tests and send them to us?: Yes No

What has been your past medical diagnosis?:

Why are you seeking a wellness consultation with a Naturopathic Doctor or Wellness Doctor?
What are main concerns you would like us to help you with?:

A physician or health practitioner informed me that I have: (check all that apply)

Overweight	Cancer	HPB	Diabetes	Immune Problems
Hepatitis	Arthritis	Stroke	Cholesterol	Mononuceosis
Migraines	Athsma	CFS	Allergies	Fibromyalgia
Thyroid	Seizures	Heart	Pneumonia	Depression
Sexually Transmitted Disease		Addictions

Other:

Your family history - parents/siblings: (check all that apply)

Diabetes	Heart	Athsma	Seizures	Allergies
HBP	Stroke	Cancer	Weight Problems	Psychological
Cholesterol	Arthritis	Alcoholism	Neurological

Other:

List all medications and or dietary supplements that you take:

Describe any trauma: (Car accidents, falls, etc.)

If you have any health problems, how long ago did you notice a change: (Please be specific)


On a scale from 1-10, rate yourself: (1 is poor, 10 is great)

	1	2	3	4	5	6	7	8	9	10

Energy Level:

Stress Level:

Emotional health:

Physical health:

Have you seen other alternative doctors or therapists?: Yes No

If so, what kind of provider?:

Other health providers you have seen over the last few years:

Do your problems interfere with your daily lifestyle?: (Sleep, sex, work, etc. - explain)

What kind of treatments have you tried to improve your problems?:

Do you experience any of the following?: (check all that apply)

Fevers	Poor Sleep	Sweat Easily	Strong Thirst	Poor Energy
Chills	Tremors	Poor Balance	Cravings	Weight Gain
Weight Loss	Depression	Localized Weakness		Memory Problems
Headaches	Sore Throats

What are three things you would want to change in your life?:
1.
2.
3.