maternal grandmother___________________	paternal grandmother___________________
maternal grandfather____________________	paternal grandfather____________________
mother______________________________	father________________________________
sisters_______________________________	brothers_____________________________
2. Who in your family has or had any of the following?(M=mother, F=father, GF= grandfather, A= aunt, etc.)

alcoholism________________________________	allergies__________________________________
arthritis______________________________	asthma______________________________
cancer______________________________________	diabetes___________________________________
eating disorder_____________________________	emphysema______________________________
glaucoma____________________________	heart disease________________________
high blood pressure_____________________	kidney disease________________________
mental illness__________________________	obesity______________________________
tuberculosis_______________________________	other____________________________________
Personal Health History
1. Check any of the following conditions which you now have or have had in the past:

abscesses	AIDS/ARC	alcoholism	allergies	anemia	anorexia
	arthritis	asthma	bloating	bulimia	cancer
colitis/lBS	compulsive eating	depression	dermatitis	diabetes	diverticulitis
emphysema	fatigue	fibromyalgia	gas	gastritis	headaches
heartburn	heart disease	hepatitis	hernia	hypertension	hypoglycemia
insomnia	jaundice	kidney disease	mental illness	mononucleosis	obesity
pain	pneumonia	rheumatic fever	sexually transmitted disease	smallpox	stroke
thyroid disorder	tonsilitis	tuberculosis	ulcer	visual problems	other

2. Do you have any problems with your skin, hair or nails? ___________________________________________

3. Do you have any problems with your teeth, bite or gums?___________________________________________

4. List all surgery you have had (include dental): ____________________________________________________  ________________________________________________________________________________________

5. Women, answer these questions about your menstrual cycle and reproductive history   age at onset of menstruation_____________________________________________________________ how often menstruation occurs___________________________________________________________ how long menstruation lasts_____________________________________________________________ premenstrual symptoms________________________________________________________________ symptoms during menstruation___________________________________________________________ frequency of napkin or tampon change on heaviest day_________________________________________ drug/hormone therapy related to menstrual cycle_____________________________________________ age at onset of menopause______________________________________________________________ how long menopause lasted (if ended)_____________________________________________________ symptoms during menopause____________________________________________________________ drug/hormone therapy during menopause___________________________________________________ number of pregnancies_________________________________________________________________ number of miscarriage_________________________________________________________ ________ number of children (include ages)_________________________________________________________ number of abortions __________________________________________________________________ drug therapy related to pregnancy (include DES)_____________________________________________ birth control methods__________________________________________________________________ vaginitis____________________________________________________________________________ last pap smear_______________________________________________________________________ last breast exam______________________________________________________________________

6. Answer these questions about your early life, if you can: drugs your mother took during pregnancy___________________________________________________ foods your mother craved during pregnancy_________________________________________________ mother’s alcohol consumption during pregnancy_______________________________________________ were you breastfed ____________________________________________________________________ age at which you were weaned, if breastfed__________________________________________________ state of health as infant_____________________ ______________________________________________ state of health as child______________________ ____________________________________________ state of health as teen ______________________ _____________________________________________ state of health as young adult______________________________________________________________

7. Mention any emotional or other traumas in your life that may have influenced your health:______________________

__________________________________________________________________________________________

8. Indicate the amount of daily consumption of:

meals_______________________________________________________

water_______________________________________________________

alcohol______________________________________________________

tobacco_____________________________________________________

coffee______________________________________________________

tea (include iced tea)___________________________________________

soft drinks/diet soda____________________________________________

sweets_____________________________________________________

sugar substitutes_______________________________________________

salty snacks __________________________________________________

9.Indicate average number per day of:

hours of sleep________________________________________________

bowel movements____________________________________________

urination  ___________________________________________________

10. Answer these questions about your elimination:

Do you have diarrhea?_______How often?__________________________

Are you sometimes constipated?___________ How often?______________

Is your elimination painful?_______________________________________

Do your stools vary with diet?_____________________________________

Do your stools vary with emotional state?___________________________

11. List all prescription drugs, over-the-counter drugs, recreational drugs, vitamins, herbs or homeopathic remedies you are currently taking:________________________________________________________________________________

____________________________________________________________________________________________

What have you previously taken:___________________________________________________________________

12. What health care providers( include alternative) are you currently seeing__________________________________

___________________________________________________________________________________________

Who have you seen in the past:____________________________________________________________________

13.   Are you satisfied with your weight?_______________________  Give a brief description of your weight history:__________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

14. What do you do for exercise?__________________________________________________________________

15. What do you do to relax?_______________________________ ______________________________________

16. How would you rate your energy level?___________________________________________________________

17. How would you rate your overall health?_______________________ ___________________________________

18. What are the major stressors in your life?___________________________________________________________

_____________________________________________________________________________________________

19. What aspects of your life do you see as nourishing?____________________________________________________

______________________________________________________________________________________________

20. What are your long-term health goals?______________________________________________________________

_____________________________________________________________________________________________

21. Anything else you’d like to add: