First Name:
Last Name:
Daytime Phone (xxx-xxx-xxxx)
Email:
Age:
Sex:
Height:
Weight:
Medical Conditions:
Current Medications:
HEAD
Headaches: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Faintness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Dizziness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Insomnia: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
5
Eyes
Watery or itchy eyes: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Swollen, reddened or sticky eyelids: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Bags or dark circles under eyes: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Blurred or tunnel vision: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
EARS
Itchy ears: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Earaches, ear infections: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Drainage from ear: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Ringing in ears, hearing loss: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
NOSE
Stuffy nose: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Sinus problems: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Hay fever: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Sneezing attacks: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Excessive mucus formation: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
MOUTH/THROAT
Chronic coughing: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Gagging, frequent need to clear throat: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Sore throat, hoarseness, loss of voice: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Swollen or discolored tongue, gums, lips: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Canker sores: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
SKIN
Acne: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Hives, rashes, dry skin: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Hair loss: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Flushing, hot flashes: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Excessive sweating: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
HEART
Irregular or skipped heartbeat: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Rapid or pounding heartbeat: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Chest pain: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
LUNGS
Chest congestion: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Asthma, bronchitis: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Shortness of breath: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Difficulty breathing: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
DIGESTIVE TRACT
Nausea, vomiting: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Diarrhea: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Constipation: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Bloated feeling: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Belching, passing gas: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Heartburn: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Intestinal/stomach pain: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
JOINTS/MUSCLE
Pain or aches in joints: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Arthritis: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Stiffness or limitation of movement: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Pain or aches in muscles: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Feeling of weakness or tiredness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
WEIGHT
Binge eating/drinking: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Craving certain foods: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Excessive weight: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Compulsive eating: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Water retention: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Underweight: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
ENERGY/ACTIVITY
Fatigue, sluggishness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Apathy, lethargy: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Hyperactivity: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Restlessness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
MIND
Poor memory: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Confusion, poor comprehension: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Poor concentration: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Poor physical coordination: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Difficulty in making decisions: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Stuttering or stammering: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Slurred speech: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
EMOTIONS
Mood swings: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Anxiety, fear, nervousness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Anger, irritability, aggressiveness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Depression: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
OTHER
Frequent illness: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Frequent or urgent urination: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
Genital itch or discharge: Past 30 days:
0
1
2
3
4
Past 48 hours:
0
1
2
3
4
I authorize Holistic Healing Health to retain and verify my client and Health Assessment information. I have read and agree to the terms and policies of the Center for Wholistic Health & Healing.
