Initial Health History
Please complete to the best of your knowledge.
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Email *
First and Last Name *
Address - Include street, city, state and zip code *
Phone Number *
Date of Birth *
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Who can we thank for referring you? Or how did you find our office? *
Occupation
What is your blood type? *
Current Height *
Current Weight *
What are your top 5 health concerns? *
What diagnosis, if any, have been given to you for these concerns?
When was the last time you felt well? *
When you started to feel ill, what was going on in your life? Did any situational, illness, or difficult/traumatic events occur? (Divorce, abuse, death in the family, accidents/falls, change in living situation, etc) -Include any age from birth to present.  *
What seems to worsen your symptoms? *
What seems to make you feel better? *
What other physicians have you seen?
How much time have you lost at work or school?
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