Health Assessment Form printable pdf download

Health Assessment Form

Patient Information

Visit Information

Name:

Date:

Address:

Visit Number:

City/State/Zip Code:

Current Weight:

Phone Number:

Current Height:

Email Address:

Date of Birth:

Age:

Patient Vitals

Office Information

Blood Pressure:

Taking any Medications?

Yes or No

Pulse:

If yes, please list them:

Temperature:

Lab Work to be Ordered:

Section One

Section Three

1. Bad breath, halitosis

Y or N

30. Head congestion / sinus fullness

Y or N

2. Loss of taste for high protein foods (meat, etc

Y or N

31. Sneezing attacks

Y or N

3. Burning (“acid”) or nervous stomach, eating relieves

Y or N

32. Dreaming, nightmare-like bad dreams

Y or N

4. Gas shortly after eating

Y or N

33. Eyes or nose watery

Y or N

5. Indigestion ½ to 1 hour after eating, may last 3-4 hours

Y or N

34. Eyes swollen or puffy

Y or N

6. Difficulty digesting fruits or vegetables; undigested food

35. Milk products and / or wheat products cause

found in stool

Y or N

distress

Y or N

7. Acid or spicy foods upset stomach

Y or N

36. Pulse and / or heart speeds after meals

Y or N

Section Two

Section Four

8. Lower bowel gas and or bloating several hours after

37. Awaken a few hours after sleep, hard to get

eating

Y or N

to get back to sleep

Y or N

9. Feet burn

Y or N

38. Crave sweets or coffee in afternoon

Y or N

10. “Whites” of eyes (sclera) yellow

Y or N

39. Overeating sweets upsets

Y or N

11. Dry skin, itchy feet and/or skin peels on feet

Y or N

40. Eat when nervous

Y or N

12. Brown spots or bronzing of skin

Y or N

41. Irritable before meals

Y or N

13. Bitter metallic taste in mouth

Y or N

42. Get “shaky” or light-headed if meals late

Y or N

14. Blurred vision

Y or N

43. Fatigue, eating relieves

Y or N

15. Headache over the eyes

Y or N

44. Heart palpitates if meals missed or late

Y or N

16. Feel nauseous, queasy or gag easily

Y or N

45. Hungry between meals/excessive appetite

Y or N

17. Color of stools light brown or yellow

Y or N

46. Muscle soreness after moderate exercise

Y or N

18. Greasy or high fat foods cause distress

Y or N

47. Loss of muscle tone or “heaviness” felt

Y or N

19. Pain between shoulder blades

Y or N

48. Enlarged heart and / or heart failure

Y or N

20. Dark circles under eyes

Y or N

49. Worrier, feel insecure and / or emotional

Y or N

21. “Acid” breath

Y or N

50. Pulse slow/below 65 or irregular pulse

Y or N

22. History of gallbladder attacks or gallstones

51. Vulnerability to insect bites

OR gallbladder removed

Y or N

(especially fleas and mosquitoes)

Y or N

23. Appetite reduced

Y or N

52. Blood pressure low

Y or N

24. Coated tongue or “fuzzy” debris on tongue

Y or N

52. Crave salt

Y or N

25. Pass large amounts of foul smelling gas

Y or N

53. Chronic fatigue/get drowsy

Y or N

26. Irritable bowel or mucous colitis

Y or N

54. Afternoon yawning

Y or N

27. Constipation, diarrhea alternating or stool alternates

55. Subject to colds, asthma, bronchitis

from soft to watery

Y or N

(respiratory disorders)

Y or N

28. Bowel movements painful or difficult, constipation,

56. Difficulty maintaining a manipulative correction

and / or laxatives used

Y or N

29. Burning or itching anus

Y or N

57. Weakness/dizziness

Health Assessment Form

Related Articles

Related forms

Related Categories