HomeoWHAT?

	Homeopathic Associates of North Texas



	"A wise man ought to realize that health is his most valuable possession." Hippocrates

Personal Health History

Name: Today’s date:

Address:
City State & Zip
Phones Home Office Cell Email Address
Occupation
Birthday
Height
Weight

Main concern
Lesser concerns

Are you currently under the care of a physician? ____ If yes, please explain:
Are you currently seeing a therapist or in a support group? ____ If yes, please explain.
What are your biggest stressors?
What do you do to relieve stress and how often?
What other information do you think it would be important to tell me?

Give date of onset or diagnosis of the following conditions that apply:

Musculo-Skeletal System Arthritis Back pain Broken bones Bursitis Chronic pain Joint pain Neck pain Numbness or tingling other	Head Ear infections Headaches Hearing problems Memory problems Migraines Vertigo / dizziness Vision problems Mouth / tooth problems other
Circulatory System Blood clots Abnormal blood Heart condition Blood pressure problems – high or low Vein problems Other	Digestive System Bloating Constipation Diarrhea Burping Gas Other
Respiratory System Allergies Asthma Breathing difficulties Bronchitis Hayfever Pneumonia Sinus problems other	Skin Allergies Athletes foot Cracks or splits Herpes, shingles Polyps Rashes Warts other
Reproductive System – Male Genital pain Prostate inflammation Sexual difficulties Sterility other	Urinary System Bladder/kidney/urinary tract infections Frequent urination Painful urination Urine leakage other
Reproductive System – Female Infertility Menopausal symptoms Menstrual irregularity Menstrual pain PMS Sexual difficulties other	Other Information Alcohol consumption Caffeine consumption Drug use Eating disorders Fatigue Nicotine/tobacco use Cancers/tumors
List any other diagnoses or surgeries

©Susan W. Kennedy 2007

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