NATUROPATHY

Empowering Health Naturally

Medical History:

Name

Please describe your current symptoms or health concerns in detail. Include when they started, how they affect your daily life, and any patterns you have noticed.

Past Medical History: Provide information about any significant medical conditions you have had in the past. Include details such as the diagnosis, treatment received, and current status of the condition.

Medications: List all medications you are currently taking, including prescription medications, over-the-counter medications, vitamins, and supplements. Include dosage and frequency.

Allergies: Specify any allergies you have to medications, foods, environmental factors (like pollen or pet dander), or other substances. Describe the type of reaction you experience.

Chronic Conditions: Detail any chronic health conditions you have been diagnosed with, such as asthma, arthritis, digestive disorders, or others relevant to your health.

Previous Treatments: Describe any previous treatments or therapies you have tried for your health concerns. Include both conventional treatments (like physical therapy or surgery) and alternative therapies (like acupuncture or herbal medicine).

Hospitalizations and Surgeries: List any surgeries you have undergone and hospitalizations you have had. Include the reason for the procedure or hospital stay, the date, and any complications or outcomes.

Family Medical History: Provide information about any significant medical conditions that run in your family, such as heart disease, diabetes, cancer, or other hereditary conditions.

Health Screenings and Tests: Note any recent health screenings or diagnostic tests you have had, such as blood tests, X-rays, MRI scans, or screenings for specific health conditions (like mammograms or colonoscopies).

Please ensure to click "Submit" at the end of each form page. After submitting, click "Next" to proceed to the following page in the questionnaire. Payment will be processed on the last page of the form.

Reminder: Click "Submit" before clicking "Next".

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NATUROPATHY

Empowering Health Naturally

Medical History:

Reminder: Click "Submit" before clicking "Next".

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