Health History Form

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HOME
CONDITIONS WE TREAT
SERVICES
BLOG
ABOUT US

HOME
CONDITIONS WE TREAT
SERVICES
BLOG
ABOUT US

Date Completed:

Patient Name

Gender

M F

Pt Occupation :

Pt Birthdate :

Is this?
Patient Parent

Do you often get sleepy after meals?

Yes No

Did/Do you enjoy school?

Yes No

Typical grades in school :

A B C D F

Tendency for Anger:

High Average Low

Tendency for Anxiety:

High Average Low

Do you experience depression?

Often Sometimes Never

Pain threshold:

High Average Low

Do you function well under stress?

Yes No

Are you competitive at sports?

Very Average No

Did you continue to grow taller after age 16?

Yes No

Please circle the symptoms or traits that currently apply to you. Write “past” next to any symptom/trait if you have experienced this earlier in life:

poor stress control poor short-term memory sensitivity to bright lights sensitivity to loud noises morning nausea affinity for spicy and salty foods tendency to delay or skip breakfast tendency to be overweight very dry skin obsessive/compulsive tendencies pale skin, inability to tan extreme mood swings high irritability and temper history of a reading disorder history of underachievement severe inner tension little or no dream recall frequent infections autoimmune disorders premature graying of hair white spots on fingernails competitive in sports ringing in the ears poor muscle development history of perfectionism “fruity” breath and/or body odor history of perfectionism “fruity” breath and/or body odor stretch marks (striae) on skin spleen-area pain severe depression severe anxiety fear of airplane travel, tornadoes, etc very strong willed obsessions with negative thoughts joint pains delayed puberty poor wound healing dark or mauve-colored urine psoriasis abnormal EEG tendency to stay up very late sleep problems seasonal allergies (ragweed, pollens, etc) social isolation enjoys spicy foods dry eyes and mouth artistic or musical ability

Medical History

Please circle any of the following that apply to a relative:

temper tantrums ADD/ADHD cancer panic disorder anxiety disorder dementia/Alzheimer’s asthma ulcers heart disease stroke bipolar disorder kidney problems depression autism psoriasis diabetes arthritis schizophrenia

NAME

Date of Birth

DATE COMPLETED

List all tablets/capsules, patches, drops, ointments, injections, etc. currently taking. Include prescription, over-the-counter, herbal, vitamin, etc. Please also list and note any medicine you take only on occasion.

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

MEDICATION LIST (Con’t)

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

Medication

Brand/Generic Name

Dosage and How Often

Reason for Taking

Date Started

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Elumind Centres For Brain Excellence is a private out-patient healthcare centre specializing in optimizing brain functions through various neurotherapeutic modalities. We deliver a comprehensive, personalized case managed collection of holistic therapies that create long-lasting lifestyle changes.

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CONDITIONS WE TREAT