JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Health Inventory
This health inventory is designed for you and members of your health care team with whom you wish to share it. Answering the questions as thoroughly as possible will provide insight into your current health status. Pulling all this information together helps one to see patterns and tendencies. The information is confidential and will not be released to any person without your request.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Address
*
Your answer
Home Phone
*
Your answer
Work Phone
Your answer
Height
Your answer
Weight
Your answer
Weight 1 year ago
Your answer
Weight 5 years ago
Your answer
Occupation
Your answer
Full time or Part time
Full time
Part time
Clear selection
Living Situation
Alone
Friends
Partner
Spouse
Children
Pets
Other:
Clear selection
Names and ages of those living with you
Your answer
What are your major health concerns and intentions for your visit today?
Your answer
Please list any other health care providers or consultants you are currently working with:
Your answer
Would you like any of therm to receive a copy of your recommendations?
Yes
No
Clear selection
Please list all herbs, vitamins, and dietary supplements you currently take, citing brand name whenever possible: Product, Dosage, and Frequency (Number/Day)
Your answer
List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over the counter (OTC) or Prescribed (P). Product, OTC or P? Dosage, Frequency (Number/Day)
Your answer
List all medications, herbs, etc., to which you have a known allergy:
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
