Met427 haq health history

Name __________________________________________________________________________________ Date of Birth _______________ Today’s Date ______________ Occupation ______________________________________________________________________ Age ______ Height ______ Sex ______ Number of Children ______ Are you recovering from a cold or flu? ____________ Are you pregnant? ____________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Date of last physical exam ___________ Practitioner name and phone number___________________________________________________________________________ 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): ❑ other __________________________________________________________________________________________________________________________________ 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: _____________________________________________________________________________ _________________________________________________ _____________________________________________________________________________ _________________________________________________ Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems): ______________________________________________________ Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months? ____________________ Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, farmer, miner)? _______________________________________________________________________________________________________________________________________________ ❑ Medical devices/prosthetics/implants, describe: ________________________________ ❑ 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: Strong dislike for any one of the following flavors: ❑ sour 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: Time of day you feel the worst or your symptoms are aggravated: ❑ 9 a.m. - 11 a.m. ❑ 11 a.m. - 1 p.m.
❑ 9 a.m. - 11 a.m. ❑ 11 a.m. - 1 p.m.
❑ 9 p.m. - 11 p.m. ❑ 11 p.m. - 1 a.m.
❑ 9 p.m. - 11 p.m. ❑ 11 p.m. - 1 a.m.
Do you experience any of these general symptoms EVERY DAY?
Medical History
Health Habits
Current Supplements
Medical (Women)
Would you like to:
Nutrition & Diet
Family Health History
(Parents and Siblings)
Food Frequency
Fruits (citrus, melons, etc.) ___________ Eating Habits
Medical (Men)
2000 Lyra Heller, Michael Katke. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law.
MET427 7/00 Rev 1/03


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