April 9, 2016

Health History Form

The ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. These questions will help to identify underlying causes of illness and will also assist us to formulate an action plan.

As you complete this form please make your own note of your answers for your records. Or for example you could take a screen shot:

  • Macbook – Press the ‘shift’, ‘cmd’ and ‘4’ keys together and then select the area to copy.
  • PC: Press ‘PrtScn’.

Please complete the whole form in one go and press submit at the bottom.

Health History Form

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20) Please select all those that apply to you:
21) In order to improve your health, how willing are you to (Rate on a scale of : 5 = very willing to 1 = not willing):
22) Rate on a scale of: 5 = very confident to 1 = not confident at all:
23) Rate on a scale of: 5 = very supportive to 1 = not supportive at all:

All information provided is confidential.

P.S. Have you completed the rest of your Intake Paperwork?: