Name
*
First Name
Last Name
Birth Date
*
Birth Date
MM
DD
YYYY
Email
Phone
(###)
###
####
Residence
Occupation (past & present)
Sport & Hobby
Medicine use
Your primary complaint
*
When did it start & was there any special situation to trigger it?
*
When you have pain, is it stinging, burning, whining, blazing, throbbing, tightness, etc?
Is the pain regular? or just sometimes? (when and how often)
*
When is the pain better? when is it worse?
*
In which mood are you generally? e.g. sad, anxious, restless, irritated, etc.
Do you wake up at night? at what time?
How is your stool?
Regular
Irregular
Stool Stoutness
solid
pulpy
soft
watery
Stool color
white
light brown
yellow brown
dark brown
black
Do you have urgent need of sweet bites?
Yes
No
Do you smoke? how much?
Do you use Alcoholic drinks? how much?
Do you use drugs? which & how often?
Do you drink coffee? how much?
What are your secondary complaints?
General
Bronchial tubes, throat, nose, ears
Heart & Vascular system
Urinary System
Stomach & Abdomen
Muscle & Joints
Skin & Hair
Conditions of
Women
Pregnancy
Vaccination
*
Can you write in chronological order: What illnesses, operations, accidents and treatments have you experienced in your life? Seemingly minor issues such as sprains, dental treatments, tonsil peeling and eczema can also be important. The childhood illnesses you've had? Any pregnancies and their course? Important developments in your life can have an influence (divorce, stress, depression, etc.)?
Apart from the above information, have you ever been treated by a physiotherapist, manual therapist, chiropractic, specialist or an alternative healer (for example: homeopath, iridologist, acupuncturist or magnetizer)?
Which illness was the worst in your life?
