FLT Health History Name* Date of Birth* Month Day Year Today's Date* Month Day Year Occupation* Age* Height* Sex* # of Children* Marital Status*SinglePartnerMarriedSeparatedDivorcedWidow(er)Are you recovering from a cold or flu?*YesNoAre you pregnant?*YesNoReason for office visit* Date Began* Date of last physical exam* Month Day Year Practitioner name and phone* Laboratory procedures performed (e.g. stool analysis, blood and urine chemistries, hair analysis)* Outcome* What types of therapy have you tried for this problem(s)* diet modification fasting vitamins/minerals herbs homeopathy chiropractic acupuncture conventional drugs other - list below Other Therapies List current health problems for which you are being treated*Current medications (prescription or over-the-counter)*Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications, (if any) and dates: Year* Surgery, Illness, Injury* Outcome* Year* Surgery, Illness, Injury* Outcome* Select the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest)*12345678910Identify the major causes of stress (e.g. changes in job, work, residence of finances, legal problems)* Do you consider yourself*underweightoverweightjust rightYour weight today* Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months?*YesNoIs your job associated with potentially harmful chemicals (e.g. pesticides, radioactivity, solvents) or health and/or life threatening activities (fireman, farmer, miner)?* Do you wear* Corrective lenses Dentures Hearing aid Medical devices/prosthetics/implants - describe below Recent changes in your ability to* see hear taste smell feel hot/cold sensations move around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers) Strong like for any of the following flavors:* sour bitter sweet rich/fatty spicy/pungent salty Strong dislike for any of the following flavors:* sour bitter sweet rich/fatty spicy/pungent salty Do you* prefer warmth (i.e. food, drinks, weather, etc.) prefer cold (i.e. food, drinks, weather, etc.) no preference Is your sleep disturbed at the same time each night?* If yes, what time?* Time of day you feel the most energy or the least symptoms* 7 AM - 9 AM 9 AM - 11 AM 11 AM - 1 PM 1 PM - 3 PM 3 PM - 5 PM 5 PM - 7 PM 7 PM - 9 PM 9 PM - 11 PM 11 PM - 1 AM 1 AM - 3 AM 3 AM - 5 AM 5 AM - 7 AM Time of day you feel the worst or your symptoms are aggravated* 7 AM - 9 AM 9 AM - 11 AM 11 AM - 1 PM 1 PM - 3 PM 3 PM - 5 PM 5 PM - 7 PM 7 PM - 9 PM 9 PM - 11 PM 11 PM - 1 AM 1 AM - 3 AM 3 AM - 5 AM 5 AM - 7 AM Do you experience any of these general symptoms EVERY DAY* Debilitating fatigue Depression Disinterest in sex Disinterest in eating Shortness of breath Panic attacks Headaches Dizziness Insomnia Nausea Vomiting Diarrhea Constipation Fecal Incontinence Urinary Incontinence Low grade fever Chronic pain/inflammation Bleeding Discharge Itching/rash Medical History* Arthritis Allergies/Hay fever Asthma Alcoholism Alzheimer's disease Autoimmune disease Blood pressure problems Bronchitis Cancer Chronic fatigue syndrome Carpal tunnel syndrome Cholesterol, elevated Circulatory problems Colitis Dental problems Depression Diabetes Diverticular disease Drug addiction Eating disorder Epilepsy Emphysema Eyes, ears, nose, throat problems Environmental sensitivities Fibromyalgia Gastroesophageal reflux disease Genetic disorder Glaucoma Gout Heart disease Infection, chronic Inflammatory bowel disease Irritable bowel syndrome Kidney or bladder disease Learning disabilities Liver or gallbladder disease (stones) Mental illness Mental retardation Migraine headaches Neurological problems (Parkinson's, paralysis) Sinus problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia Sexually transmitted disease Seasonal affective disorder Skin problems Tuberculosis Ulcer Urinary tract infection Varicose veins other, list here: Medical (Men) Benign prostatic hyperplasia (BPH) Prostate cancer Decreased sex drive Infertility Sexually transmitted disease other, list here: Medical (Women) Menstrual irregularities Endometriosis Infertility Fibrocystic breasts Fibroids / ovarian cysts Premenstrual syndrome (PMS) Breast cancer Pelvic inflammatory disease Vaginal infections Decreased sex drive Sexually transmitted disease other, list here: Age of first period* Date of last gynecological exam* Mammogram*YesNoPap*YesNoForm of birth control* # of children* # of pregnancies* C-sections* Menopause*Surgical menopauseNatural menopauseHaven't gone through it yetDate of last menstrual cycle Length of cycle (days)* Interval of time between cycles (days)* Any recent changes in normal menstrual flow (e.g. heavier, large clots, scanty)* Family Health History (Parents and siblings)* Arthritis Asthma Alcoholism Alzheimer's disease Cancer Depression Diabetes Drug addiction Eating disorder Genetic disorder Glaucoma Heart disease Infertility Learning disabilities Mental illness Mental retardation Migraine headaches Neurological disorders (Parkinson's, paralysis) Obesity Osteoporosis Stroke Suicide other, list here: Health HabitsTobacco: Cigarettes #/day* Tobacco: Cigars #/day* Alcohol: Wine: #glasses / d or wk* Alcohol: Liquor: #ounces / d or wk* Alcohol: Beer: #glasses / d or wk* Caffeine: Coffee: #6 oz cups/day* Caffeine: Tea: #6 oz cups/day* Caffeine: Soda w/caffeine: #cans/day* Other sources: Water: #glasses/day* Exercise* 5-7 days per week 3-4 days per week 1-2 days per week 45 minutes or more duration per workout 30-45 minutes duration per workout Less than 30 minutes Walk Run, jog, jump rope Weight lift Swim Box Yoga Nutrition & Diet* Mixed food diet (animal and vegetable sources Vegetarian Vegan Salt restriction Fat restriction Starch/carbohydrate restriction The Zone Diet Specific food restrictions* Dairy Wheat Eggs Soy Corn All gluten other food restrictions, list here: Food Frequency (servings per day) Fruit (citrus, melon, etc.)* Dk green/deep yellow/orange vegetables* Grains (unprocessed)* Beans, peas, legumes* Dairy, eggs* Meat, poultry, fish* Eating habits* Skip breakfast Two meals/day One meal/day Graze (small frequent meals) Food rotation Eat constantly whether hungry or not Generally eat on the run Add salt to food Current Supplements* Multivitamin/mineral Vitamin C Vitamin E EPA/DHA Evening Primrose/GLA Magnesium Zinc Friendly flora (acidophilus) Digestive enzymes Amino acids CoQ10 Antioxidants (e.g. lutein, resveratrol, etc.) Herbs - teas Herbs - extracts Chinese herbs Ayurvedic herbs Homeopathy Bach flowers Protein shakes Superfoods (e.g. bee pollen, phytonutrient blends) Liquid meals Calcium, source* Minerals, describe* other supplements, list here:* Would you like to:* Have more energy Be stronger Have more endurance Increase your sex drive Be thinner Be more muscular Improve your complexion Have stronger nails Have healthier hair Be less moody Be less depressed Be less indecisive Feel more motivated Be more organized Thick more clearly and be more focused Improve memory Do better on tests in school Not be dependent on over-the-counter medications like aspirin, ibuprofen, antihistamines, sleeping aids, etc. Stop using laxatives or stool softeners Be free of pain Sleep better Have agreeable breath Have agreeable body odor Have stronger teeth Get less colds and flus Get rid of your allergies Reduce your risk of inherited disease tendencies (e.g. cancer, heart disease, etc.) Let us know you are human
