Health History Form – 2020

    Health History Form - 2020

    Date Completed:
    Patient Name
    Gender

    Pt Birthdate :
    Is this?
    Is this?
    Do you often get sleepy after meals?
    Did/Do you enjoy school?
    Typical grades in school :
    Tendency for Anger:
    Tendency for Anxiety:
    Do you experience depression?
    Pain threshold:
    Do you function well under stress?
    Are you competitive at sports?
    Did you continue to grow taller after age 16?
    Please circle the symptoms or traits that currently apply to you. Write “past” next to any symptom/trait if you have experienced this earlier in life:
    Medical History
    Please circle any of the following that apply to a relative:

    Date of Birth
    DATE COMPLETED
    List all tablets/capsules, patches, drops, ointments, injections, etc. currently taking. Include prescription, over-the-counter, herbal, vitamin, etc. Please also list and note any medicine you take only on occasion.
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started

    MEDICATION LIST (Con’t)

    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started
    Medication
    Brand/Generic Name
    Dosage and How Often
    Reason for Taking
    Date Started