New Patient Questionnaire
Name: __________________________________________________________
Address:
__________________________________________________________
__________________________________________________________
Email:
____________________________________________________________
Contact
Phone Numbers: ____________________________________________
DOB: ____________________________________________________________
Date: ____________________________________________________________
MAIN PROBLEM
1. What is the Chief Complaint (main problem) you are coming in for today?
2. When did this problem begin? What happened in your
life around that time? What do you think caused it?
3. What aggravates the problem (certain types of food or weather, movement, light, noise, heat/cold,
or anything else you can think of)?
4. At what time of the day or night is the problem the worst?
Specify an hour if you can.
5. What symptoms can you identify that accompany the problem?
WOMEN
6. Number of pregnancies _____ number of children
____ number of miscarriages ____ number of abortions ___
7. At what age did menses (period) begin? If you have gone through menopause, at what age?
8. How frequently does (or did) your period come?
9. What about the duration, abundance, color, time
of day when flow is greatest, any odor or clots?
10. How do you (did you) feel before, during and after
menses? Any PMS symptoms?
HEALTH HISTORY
11. Please provide brief health history.
12. Frequency of bowel movements (BM): If you don’t
have a BM, do you use laxative?
13. How frequently do you get colds and flu?
14. Have you had any childhood illnesses twice, or in
a very severe form or after puberty?
15. Have you had vaccinations since the standard childhood
ones? Have you ever had an adverse reaction or unusual reaction to vaccinations?
16. Have you had any surgery? What type and when?
17. What other medical problems/diagnoses have you been treated for.
18. List or give sheet of present medications you are taking—tell us to the best of your knowledge
the reason you were prescribed this medication. How long have you been taking each medication?
19. List any supplements (vitamins) and herbs you are taking or give a sheet with them and tell us
to the best of your knowledge why you are taking them and how long you have been taking them.
20. Are you presently on any Homeopathic remedies? If so, which one and what is the potency, dose and
how often do you take it? Have you had any adverse reactions or aggravations to any remedies?
21.
MEDICATIONS: List any medication you are now taking:
______________________________________________________________________
______________________________________________________________________
22.
DIET:
Food Likes/dislikes? ___________________________________________________________________________________
____________________________________________________________________________________
23. Please list any other concerns or questions you would like to discuss.
Health Questionnaire
If you have been bothered recently by any of these problems check yes:
Y N
Y N
__ __ migraines __ __ headaches
__ __ dizziness
__ __ loss of consciousness
__ __ convulsions
__ __ loss of balance
__ __ dizzy spells
__ __ fainting/blackouts
__ __ blurry vision
__ __ eye pain or itching
__ __ double vision
__ __ear pain
__ __ hearing loss
__ __ ringing in ears
__ __ vertigo __
__ dental problems
__ __ sore or bleeding gums __ __ nose/sinus congestion
__ __ sneezing
__ __ nose bleeds
__ __ sore throats
__ __ vomiting blood
__ __ difficulty swallowing
__ __ wheezing or gasping
__ __ frequent coughs
__ __ hay fever
__ __ chest colds
__ __ allergies
__ __ chest pains
__ __ shortness of breath
__ __hemorrhoids
__ __ yellow jaundice
__ __ difficulty sleeping
__ __ motion sickness
__ __ excessive sweating
__ __ indigestion
__ __ frequent belching
__ __ nausea
__ __ vomiting
__ __ pain in abdomen
__ __ bloated abdomen __
__ constipation
__ __ loose bowels
__ __ black stools
__ __ pain in rectum
__ __ itching of rectum
__ __ rectal bleeding
__ __ frequent urination
__ __ involuntary urination
__ __ burning on urination
__ __ blood in urine
__ __constant urge for urination
__ __ aching muscles or joints
__ __ swollen joints
__ __ back or shoulder joints
__ __ joint pain
__ __ trembling
__ __ numbness
__ __leg cramps
__ __ unexplained fevers
__ __ slow healing wounds __
__ bruise easily
__ __ bleeding easily __
__ prolonged bleeding
__ __ heat intolerance
__ __ cold intolerance
__ __ lack of concentration
__ __ loss of memory
__ __ depression
__ __ frequent crying
__ __ worrisome
__ __ cry easily
__ __ shy or sensitive
__ __ dislike criticism
__ __ angered easily
__ __ nervousness
__ __ restlessness __
__ anxiety
__ __ heart palpitations
__ __ high blood pressure
__ __ skin problems
__ __ eczema
__ __ acne
__ __ hives
__ __ weight gain
__ __ weight loss
__ __ anemia
__ __ appetite change
__ __ fatigue or weariness
__ __ insomnia
__ __ change of sexual energy
__ __ thyroid problems
__ __ moodiness
__ __ warts
__ __ polyps
__ __ cysts
__ __ excessive fear
__ __ irritability
__ __ varicose veins
__ __ heartburn
__ __ artificial organs __
__ cataracts
__ __ poison Ivy
__ __ broken bones
__ __ spine curvature
Men Only
__ __ burning or discharge
__ __swelling on testicles
__ __ painful testicles
Women Only
__ __ painful menstruation __
__ missed periods
__ __ menstrual problems __
__ hot flashes
__ __ heavy bleeding __
__ vaginal discharge
__ __ genital irritation __
__ pain on intercourse
__ __ swelling of breasts __
__ uterine fibroids
__ __ endometriosis
__ __ menopause
List comments or special
problems:
Family History Questionnaire
Place an (X) in the appropriate column for any illness that you or your relatives
have had.
ILLNESS
Self Father Mother Brothers Sisters Child Grandparents
Abnormal periods________________________________________________________________
Alcohol/drugs___________________________________________________________
Allergies_______________________________________________________________
Anemia________________________________________________________________
Arthritis/Gout___________________________________________________________
Asthma________________________________________________________________
Bleeding Problems______________________________________________________________
Cancer________________________________________________________________
Diabetes_______________________________________________________________
Eczema_______________________________________________________________
Emphysema____________________________________________________________
Epilepsy_______________________________________________________________
Frequent infections______________________________________________________________
Heart trouble________________________________________________________________
Hepatitis______________________________________________________________
High blood pressure______________________________________________________________
Kidney problems______________________________________________________________
Mental ILLness_______________________________________________________________
Migraines______________________________________________________________
Polio__________________________________________________________________
Pneumonia_____________________________________________________________
Prostate problems_________________________________________________________
Psoriasis______________________________________________________________
Rheumatic fever__________________________________________________________
Stomach Problems________________________________________________________
Stroke__________________________________________________________________
Thyroid Problems_________________________________________________________
Tuberculosis_____________________________________________________________
Ulcers__________________________________________________________________
Venereal disease_________________________________________________________
Weight problems_________________________________________________________
