Natural Healing Center Health Questionnaire Name * First Name Last Name Email * Date of Birth * MM DD YYYY Phone Number * Reason for visit: * What precedes it? What else is going on when it happens? List of prescription medications, supplements, allergies: List surgeries that need to be known Do any of the following apply to you: Hemophiliac Heart condition Lung condition Pacemaker Epilepsy Taking anticoagulant medications Cancer Contagious illness List any disorder you've had in the past: Sleep and Rest Take a long time to fall asleep Night sweats Toss & turn all night Wake up between 1 & 3 am Palpitations Chest tightness Recurring dreams or nightmares Sweat when anxious Do you start the day with energy and get tired in the afternoon Yes No Sometimes Lung System Shortness of breath Asthma Breathing difficulties Environmental allergies Sinus issues Catch colds & flu easily Take a long time to recover from illness Nasal drip Sleep apnea Mental Health and Memory Poor short-term memory Poor long-term memory Can't retain information Poor focus/concentration Worry Overthink Oversensitive Irritable Frustrated Angry Feeling stuck Depressed Sad Feeling blue Can't make decisions Self doubt Low self-esteem Difficulty in letting go Envious Jealous of others Stress level 1-Low 2 3 4 5-high Anxiety level 1-Low 2 3 4 5-high Hearing and Sight Tinnitus high pitch Tinnitus low pitch Ear pain Ear feeling stuffy Blurred vision Floaters/ spots Poor night vision Dry eyes Eye twitching Tearing when windy or crusty eyes Women's health Bloating Cravings Fatigue Lower back pain Ovulation pain Abnormal vaginal discharge Pregnant Do you have cramp? Yes No Sometimes PMS? Yes No Sometimes Tender breasts? Yes No Sometimes Have or are you going through menopause Yes No Hot flushes Yes No Sometimes Vaginal dryness Yes No Sometimes Are you pregnant? if so how many weeks Urination Dark little amounts of urination Strong smelling urine Dribbling urination Frequent urgent urination Painful urination - burning Bladder incontinence Getting up at night to urinate. Premature grey hair Hair loss History of broken bone(s) Swelling of the lower legs Energy levels 1-low 2 3 4 5 - high Is your energy levels causing Mental fatigue Difficulty in getting out of bed in am Not hungry for breakfast Poor appetite Bloating after meals Cravings Explain your current diet Stomach and digestion Sores in the mouth Sores on the tongue Bad breath Bleeding gums Acid reflux-heartburn Dry mouth Thirst for cold drinks Constant hunger Skin History of bad skin Acne Eczema Psoriasis Dry Skin Greasy skin Location of skin problem Bowels Constipation Straining while having a bowel movement (BM) Gas Unfinished feeling after BM Loose stools Diarrhea Smelly diarrhea Blood in stools Urgent painful diarrhea Alternating diarrhea & constipation Hard, small, dry pebble-like stools Sticky stools: Undigested food in the stool Headaches Frontal and orbital (front / like a band around the head) Temporal (sides of the head) Occipital (back of the head) Whole head Vertex (pain in eye region) Better with heat Better with cold Hot at night Migraine Better with rest Better with exercise Mild Stabbing Moving pain Vomiting Dizziness Nausea Temperature Cold hands Cold feet Hot palms Hot souls Cold body Hot body Cold nose Hot at night Loves summer Prefer winter Loves cold foods Loves hot foods Alternate between hot and cold Does not like extreme temperature changes Musculoskeletal Constant pain Comes and goes Stiffness Local pain Swelling Travelling pain Poor range of motion Better with heat Better with cold Better with rest Better with exercise Better with massage Pain level: 1-low 2 3 4 5 - High Text Area Terms and Conditions * I have read Thank you!
