Bowel Movement Regular / irritable / Menstruation Normal / Menopause / constipated / erratic Problematic (describe) Are you pregnant? / Yes / No Muscle / No / Yes (describe) Age(s) of children pain / stiffness Asthma / Other (describe) High BP / Low BP / Arrhythmia Breathing Heart / Circulation / /Heart Attack / Other: Blood Pressure Nervous System Stroke / Fainting / Headaches Migraine / Tension / other Dizziness / Numbness Pins (Give & Needles /Other frequency) Problems with eyes No / Yes (describe) Skin problems No / Yes (describe) /ears /nose /mouth? Typical diet Mealtimes Regular / erratic / eat late in the evening Do you drink alcohol? Yes / No Do you smoke? Yes / No How many units/week? How much? Do you drink caffeine? Exercise Type & How much per day? frequency Family Medical History Please list any chronic Mother: health conditions: Father: Grandparent: Sibling: Please list any previous Surgeries: or current events: Accidents/Injuries: Illness: Mind & Emotions Worry /anxiety / stress depression/ hyperactive irritable/other The above information is correct and complete and I am willing to provide further information in follow up sessions. The signature below covers data privacy and liability waver statements on page 3 of this form. Signed and date (Print name ) Data Privacy statement: Please note that your personal data will be stored and used in accordance with our Privacy Statement below.
Bowel Movement Regular / irritable / constipated / erratic Menstruation Normal / Menopause / Problematic (describe) Are you pregnant? / Age(s) of children Yes / No Muscle / pain / stiffness No / Yes (describe) Breathing Asthma / Other (describe) Heart / Circulation / Blood Pressure High BP / Low BP / Arrhythmia /Heart Attack / Other: Nervous System Stroke / Fainting / Dizziness / Numbness Pins & Needles /Other Headaches (Give frequency) Migraine / Tension / other Problems with eyes /ears /nose /mouth? No / Yes (describe) Skin problems No / Yes (describe) Typical diet Mealtimes Regular / erratic / eat late in the evening Do you drink alcohol? How many units/week? Yes / No Do you smoke? How much? Yes / No Do you drink caffeine? How much per day? Exercise Type & frequency Family Medical History Please list any chronic health conditions: Mother: Father: Grandparent: Sibling: Please list any previous or current events: Surgeries: Accidents/Injuries: Illness: Mind & Emotions Worry /anxiety / stress depression/ hyperactive irritable/other The above information is correct and complete and I am willing to provide further information in follow up sessions. The signature below covers data privacy and liability waver statements on page 3 of this form. Signed and date (Print name ) Data Privacy statement: Please note that your personal data will be stored and used in accordance with our Privacy Statement below.
Clinic_HealthInformation_2018-VDT-web.docx