Health Assessment Form

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Personal Details of Patient

Name
Date of birth
Gender
Do you have health insurance?

Details of your PARTNER or SPOUSE

Partner/Spouse Name
Partner/Spouse Gender

Background

Give us as much info as you can

Medical & Surgical Conditions

Please list all medical and surgical CONDITIONS or symptoms which are a problem to you now. SINCE WHEN you have had it, WHEN it occurs, and what makes it BETTER or WORSE. If possible, you can tell us in which year each condition was diagnosed, and how the diagnosis was made (e.g. by a doctor, with a scan, etc.)."

Information

Please complete all of the below information.
cm
kg
km
meters
Do you need assistance with

Remedies

Please list all natural remedies and supplements/herbs you use, and indicate how frequently you use them:

Treatment History

Write down all the MEDICATIONS you are taking NOW and include dosage and frequency. (Include birth control pills, pain medications, diet hormones, vitamins, minerals, and supplements.)