Date Today
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MM
DD
YYYY
Name
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First Name
Last Name
Email
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Phone
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(###)
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Emergency Contact
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Occupation
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Date of Birth
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MM
DD
YYYY
Place of Birth
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Status
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Single
Married
Separated
Divorced
Widowed
Blood Group/Type
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Height (in feet and inches)
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Weight (in pounds)
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Children and Ages
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Do you have any children? If yes, please indicate how many and their ages.
Notes on Family Life or Home Situation
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Recreational Interests
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Exercise Activities
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Overall daily stress level (0 low - 10 high)
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Overall daily energy level (0 low - 10 high)Overall daily energy level (0 low - 10 high)
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Other Notes or Thoughts
Other Frequented Specialists
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Only answer if applicable; otherwise, indicate 'N/A' or 'None'.
Food Allergies or Food Intolerances
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Only answer if applicable; otherwise, indicate 'N/A' or 'None'.
Current symptoms and cite reason(s) why seeking treatment? Do a HEAD to TOE scan (internal + external). List ALL current symptoms.
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Give an account of symptoms, whether you're receiving treatment, any alleviating or aggravating factors, or associated symptoms; include your response to your illness and its effects on home, relationships, social activities, worries, and general self-esteem.
If there is a diagnosis, what is the diagnosed condition?
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Only answer if applicable; otherwise, indicate 'N/A' or 'None'.
Date/year of onset
Medical Opinion and Treatment Recommended
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Only answer if applicable; otherwise, indicate 'N/A' or 'None'.
Details of Treatment
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List dates of the start of each treatment. (Only answer if applicable; otherwise, indicate 'N/A' or 'None.')
A. Prognosis if you undertake the recommended treatment
B. Prognosis if you decline treatment
A. Overall survival, with recommended treatment
% of people who survived? and length of time people survived?
B. Disease-free survival w recommended treatment
% of people who survived disease-free? Length of time disease-free people survived?
C. No expected disease-free survival w recommended treatment: Response rate with suggested treatment?
% of people who responded? % of shrinkage if tumoural masses?
D. Prognosis when NOT doing recommended treatment?
Description
Start?
What tests where undertaken?
Specify the treatment(s) that were undertaken.
Chemotherapy, radiation, hormone treatment (drug type), surgery, or other. (Provide details and include the start date and length of treatment).
Current medication
Specify brand, dose, and length of time prescribed. (i.e., Vioxx, 2 years, 50mg 2x/day)
Past medication
Specify brand, dose, and length of time prescribed
0-10 Years Old
11-20 Years Old
21-30 Years Old
31-40 Years Old
41-50 Years Old
51-60 Years Old
61-70 Years Old
71-100 Years Old
Family Medical History
As a child/adolescent (including food habits)
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As an adult (including food habits)
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Number of meals in a day
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Number of cups of tea/coffee
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Food Cravings?
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(type, frequency, time/day or month)
Food allergies? Food intolerances? Symptoms?
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Alcohol intake?
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Daily fluid intake? (other than alcohol)
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Experience a lack/excess of appetite?
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BREAKFAST
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Indicate time. What (quality) and portion size (quantity)
LUNCH
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Indicate time. What (quality) and portion size (quantity)
DINNER
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Indicate time. What (quality) and portion size (quantity)
SNACKS
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Indicate time. What (quality) and portion size (quantity)
Details of Menstruation
Year of onset or menopause. Irregularities. Length of cycle. Flow.
On/has taken contraceptive pill. On/has taken any other hormonal treatment pill.
Medication. Length of time prescribed. Dates /year. Side effects? Other.
Details of Birth
Induced, forceps used, cesarean, premature, jaundice, toxemia, or other complications during pregnancy? (Only answer if applicable; otherwise, indicate 'N/A' or 'None'.)
Have you had any problems with the following?
Miscarriages
Terminations
Complications
Infertility
Indicate date/year and treatment
What are your health goals?
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Please describe any limitations or barriers that may be impacting your ability to reach your health goals.
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Additional Notes or Thoughts
