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First, Middle, and Last Name Mailing address Age Date of birth (month/date/year) Best phone number to reach you, including area code Is it ok to leave a message at this number? Email, if you wish to receive communication this way Emergency contact number including area code Relationship to you Current occupation Highest level of education completed Grade School High School College Graduate Post Graduate Marital status Married Separated Divorced Widowed Living with Engaged Other Spouse's first, middle, last name How many children do you have? Who lives at home with you? Current height and weight Please describe your primary concern. Indicate the severity on a scale of 1-10, 10 being most severe. Describe when this began, what makes it worse, what makes it better, and what other care you have received for this concern. Please describe a secondary concern. Indicate the severity on a scale of 1-10, 10 being most severe. Describe when this began, what makes it worse, what makes it better, and what other care you have received for this concern. If applicable, please describe a third concern. Indicate the severity on a scale of 1-10, 10 being most severe. Describe when this began, what makes it worse, what makes it better, and what other care you have received for this concern. If applicable, please describe a fourth concern. Indicate the severity on a scale of 1-10, 10 being most severe. Describe when this began, what makes it worse, what makes it better, and what other care you have received for this concern. If applicable, please describe a fifth concern. Indicate the severity on a scale of 1-10, 10 being most severe. Describe when this began, what makes it worse, what makes it better, and what other care you have received for this concern Please list and briefly describe any other current diagnoses. Please list past surgical history, including surgeries and the year.  Please list any traumatic injuries and the year that they occurred. Please list any family history of illness, including siblings, mother, father, mother's parents, and father's parents. Please list any substances used, including tobacco, alcohol, and other recreational drugs. Please indicate daily amount used, number of years used, and, if applicable, when you quit. Please list any food, medication, or environmental allergies and the reactions you have to each. Please list any prescribed medications you are currently taking, the dosages, and your reason for taking them. Please list any over the counter medications, the dosages, and your reason for taking them. Please list any supplements, herbs, or vitamins, the dosages, and your reason for taking them. Please describe your exercise routine, including specific type of exercise (ie, jogging, biking, weight lifting), minutes per day, and times per week. Please list all foods and beverages you have consumed in the last 24 hours, including breakfast, lunch, dinner, all snacks in between meals, water (approx. number of glasses), coffee/tea (approx. number of cups), and soda (approx. number of servings). On a scale of 1 (minor)-10 (severe), what is your level of fatigue? 1 2 3 4 5 6 7 8 9 10 On a scale of 1 (minor) - 10 (severe), how much do you struggle with sleep problems? 1 2 3 4 5 6 7 8 9 10 On a scale of 1 (minor) - 10 (severe), what is your level of emotional stress? 1 2 3 4 5 6 7 8 9 10 On a scale of 1 (minor) - 10 (severe), what is your level of physical stress? 1 2 3 4 5 6 7 8 9 10 Neurological:  Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Declining memory Dizziness Foggy thinking Headaches History of head injury History of stroke History of TIA Sensitivity to light Loss of balance Loss of sensation (touch) Migraines Peripheral neuropathy Problems with mental focus Seizures Tremors Weakness Other Please add any additional neurological symptoms your are experiencing Mental/Emotional: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Anorexia Anxiety Bulemia Confusion Depressed mood Emotional fluctuations History of Trauma Restlessness Suicidal actions Suicidal thoughts Other Please add any additional mental/emotional symptoms you are experiencing Eyes, Ears, Nose, Throat: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Blurry vision Cataracts Cold or canker sores Congenstion Dark circles Dental problems Difficulty hearing Difficulty swallowing Dizziness Double vision Dryness of eyes, throat, etc. Earaches Eye pain/red eye Fainting/blackouts Frequent colds/infection Glasses/contacts Glaucoma Grinding teeth Hair loss Hay fever Head injury Hoarse voice Loss of smell Neck lumps/swelling Neck pain Nosebleeds Puffy eyes Ringing in ears Sensitivity to light Sinus problems Sore throat Sore tongue Sore/bleeding gums Tearing in eyes Respiratory:  Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Asthma Bronchitis Chest colds Chest pain Coughing Coughing up blood Coughing up sputum Emphysema Heart palpitations High blood pressure Pneumonia Shortness of breath Swollen ankles Wheezing Cardiac:  Please select all that apply (past or current)  by holding the ctrl or apple button and clicking on your selections Activity intolerance Aneurysm Angina Bacterial endocarditis Congenital heart defect High blood pressure High cholesterol History of chest pain History of heart attack Irregular heart beat Leg pain with activity Pacer Valve problem Gastrointestinal: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Blood in stool Blood in vomit Constipation Diarrhea Difficulty swallowing Excessive appetite Gas/bloating Hemorrhoids Indigestion Light colored stool Mucus in stool Nausea Rectal pain Stomach pain Undigested food in stool Vomitting Yellow eyes or skin Genito-urinary:  Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Bladder infections Blood in urine Change in urine/color Difficulty urinating Frequent urination Genital sores Genital discharge Incontinence Kidney stones Odorous urine Pain with urination Sexual difficulty STDs Urge to urinate Musculoskeletal: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Aching muscles Cramps Discomfort at joints Numbness/tingling Restless legs Swollen joints Weakness Please describe any other areas of Musculoskeletal tenderness Skin: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Acne Boils Color change Easy bruising Fungus Hives Itching Lesions Lumps Moles Rashes Warts Endocrine: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Always cold Always hot Chronic fatigue Increased/decreased hunger Increased/decreased thirst Thyroid problems Blood/Immune: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Autoimmune disease Bruising Frequent bleeding Frequent flu/colds Painful lymph nodes Slow wound healing Swollen glands Male Reproductive: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Discharge Erection difficulty Hernias Infertility Painful erections Painful testicles Painful urination Premature ejaculation Prostate problems Sexual difficulties Swelling in testicles Testicular masses Female Reproductive: Please select all that apply (past or current) by holding the ctrl or apple button and clicking on your selections Body hair Breast pain Difficulty conceiving Facial hair Genital eruptions Heavy periods Lack of sexual desire Lumps in breast(s) Missed periods Nipple discharge Orgasm difficulty Pain with intercourse Painful menses Pelvic pain PMS Spotting STDs Use birth control Vaginal discharge Vaginal dryness Vaginal itching Vaginal burning Yeast infections Please indicate the number of live births, pregnancies, and spontaneous or missed miscarriages you have had: How did you learn about this practice?