Form #3

Family Health History

Please fill out all fields to the best of your ability

Name*
First Last
Sex*
- Male
- Female
Personal Health History
The items below may relate to your current condition. Please CHECK the symptoms in the column if you are CURRENTLY troubled or if you have EVER HAD a particular symptom.
General
- Abnormal weight loss / gain
- Alcoholism / drug abuse
- Allergies
- Blood / bleeding problems
- Breast lumps / soreness
- Cancer
- Depression / anxiety
- Diabetes
- Excessive thirst
- Fever / chills without flu
- ⁯General fatigue
- ⁯Night sweats
- ⁯Poor sleep
- ⁯Thyroid disease / goiter
Gastrointestinal
- ⁯Abdominal pain
- Appendicitis
- ⁯Belching / gas
- ⁯Black / bloody stools
- Constipation
- Diarrhea
- ⁯Gallbladder problems
- Hemorrhoids
- Hernia
- ⁯Liver problems / jaundice
- ⁯Frequent nausea / vomiting
- ⁯Pain over abdomen
- ⁯Poor appetite
- ⁯Poor digestion
- ⁯Ulcer / heartburn
Eye, Ear, Nose, and Throat
- ⁯Deafness / difficulty hearing
- ⁯Dental problems
- ⁯Ear noises / ringing
- Hoarseness
- Nosebleeds
- ⁯Nose problems
- ⁯Pain in / behind eyes
- ⁯Sinus problems / hay fever
- TMJ
- ⁯Tonsil problems
- ⁯Visual disturbances
Cardio-Respiratory
- ⁯Ankle swelling
- ⁯Asthma / wheezing
- ⁯Chest pains
- ⁯Chronic cough
- ⁯Difficulty breathing
- Emphysema
- ⁯High blood pressure
- ⁯High cholesterol levels
- ⁯Irregular heartbeat
- ⁯Previous heart trouble
- ⁯Rheumatic Fever
- ⁯Spitting phlegm / blood
- Stroke
- Tuberculosis
- ⁯Varicose veins
Skin
- ⁯Bruising easily
- ⁯Change in mole(s)
- ⁯Itching / eczema / rash
- ⁯Skin cancer
Genitourinary
- ⁯Blood in urine
- ⁯Difficulty starting flow
- ⁯Frequent urination
- ⁯Frequent night urination
- ⁯Inability to control flow
- ⁯Kidney disease / stones
- ⁯Painful urination
- ⁯Sexual difficulties
- ⁯Urinary tract infection
- ⁯Venereal infection
Women Only
- Endometriosis
- ⁯Excessive flow
- ⁯Irregular cycles
- ⁯Hot flashes
- ⁯Painful periods
- PMS
- Pregnancy
- ⁯Vaginal burning / itching
Number of births*
Please enter a number from 0 to 20.
Date of last PAP test
MM slash DD slash YYYY
Men Only
- ⁯Testicular swelling / pain
- ⁯Prostate problems
Neurological
- Convulsions
- Dizziness
- Fainting
- Headache
- ⁯Mental disorder
- ⁯Numbness / tingling
- ⁯Twitching / tremors / epilepsy
- Weakness
Musculoskeletal
- ⁯Neck pain
- ⁯Pain between shoulders
- ⁯Low back pain
- ⁯Hip / knee / ankle / foot pain
- Osteoporosis
- ⁯Rheumatoid arthritis
- ⁯Shoulder / elbow / wrist / hand pain
- Scoliosis
Height*
Weight*
Please enter a number from 0 to 1500.
Family Health History
(Brothers, sisters, parents, grandparents only)
Check any symptom that any of these family members have / had
- Cancer
- Diabetes
- ⁯High blood pressure
- ⁯Heart disease
- Stroke
- ⁯Kidney disease
- ⁯Muscle / bone / nerve / disease
- ⁯Thyroid disease
Personal Health History Continued
Have you had any injuries in the past?*
(This includes auto / sports injuries and falls)
- Yes
- No
List any past injuries and when they occurred*
Have you had any surgeries or hospitalizations?*
- Yes
- No
List all surgeries and hospitalizations with dates for each occurrence*
Please describe any serious condition or disease you have or had (even if it is included on the check-off list), including when it occurred and the outcome of treatments received
Agreement*
I have completed this form to the best of my ability as I understand that Jennifer Corey is relying upon this information to make treatment recommendations
Consent Statement*
By entering my full name in the field below, I am signing the form
Client Signature*

If the client is not yet 18 years old, a parent or guardian must sign.
Today's Date*
MM slash DD slash YYYY
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Form #3

Family Health History

Personal Health History

Family Health History

Personal Health History Continued

Jennifer Corey

480.747.8902

9312 E. Raintree Drive

Scottsdale, AZ 85260

Jennifer@magnoliatherapeutics.net