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Basic Medical History

Patient Name:________________________________________ Date:______/_______/_________


Allergies: (List all known allergies):________________________________________________________________________
_______________________________________________________________________________________________________

MEDICINES USED IN THE PAST THREE (3) MONTHS:


Antibiotics Y N Antacids YN Antispasmodic Y N
Laxatives Y N Antihistamines Y N Muscle Relaxant Y N
Tranquilizer Y N Sedative Y N Sleeping Pill Y N
Antidepressant Y N Stimulant Y N Diet / Wt Control Y N
Water Pill Y N Heart Medicines Y N Blood Pressure Pill Y N
Cortisone Y N Inhaler Y N Thyroid Hormone Y N
Hormone Pill Y N Contraceptive Pill Y N Anti-inflammatory YN
Asthma Meds Y N Nasal Decongestant Y N Pain Pill / analgesic Y N
Aspirin Y N Anticonvulsant Y N B-12 Injection Y N
Steroids Y N For Cholesterol Y N Cough / cold Meds Y N
Anti-Ulcer Med Y N Liver Meds Y N Potassium Pill Y N

Check any of the following in the last thirty (30) days with a √ or In the Past with an X
_____ Heart Disease _____ Underweight _____ Cancer
_____ Diarrhea _____ Overweight _____ Candida
_____ Parasites _____ Diabetes _____ Body Odor
_____ Colitis _____ High Cholesterol _____ High Blood Pressure
_____ Ulcerative Colitis _____ Heartburn _____ Low Blood Pressure
_____ Bowel Impaction _____ Obesity _____ Dizziness
_____ Hemorrhoids _____ Frequent Headaches _____ Fainting Spells
_____ Diverticulitis _____ Migraine Headaches _____ History of Seizures
_____ Bloody/Black Stools _____ Nervousness _____ Bloating
_____ Low Blood Sugar _____ Insomnia _____ Hepatitis
_____ Ulcers _____ Irritability _____ Shortness of Breath
_____ Hernia _____ Anemia _____ Chronic Cough
_____ Crohn’s Disease _____ Arthritis _____ Emphysema
_____ Abdominal Pain _____ Painful Menstruation _____ Bronchitis
_____ Vomiting _____ Vaginal Discharge _____ Asthma
_____ Prostate Trouble _____ Breast Pain _____ Poor Circulation
_____ Liver Problems _____ Fatigue _____ Enlarged Thyroid
_____ Kidney Infection or Stones _____ Depression _____ Double/Blurred Vision
_____ Kidney Failure _____ Painful Urination _____ Gallbladder Disease

Are you now under a doctor’s care?_____ if so, please explain__________________________________________________

Doctor’s name_______________________________________________________ Telephone________________________

List any surgeries_________________________________________________________________________________________

List all medications and supplements you now take regularly (include over-the-counter)_______________________________

_______________________________________________________________________________________________________

Are you pregnant?__________ If so, what trimester?____________

___________________________________________________________________ ____________________________
Signature Date
Basic Medical History
Page 2

Y N Have you been treated with antibiotics for acne?


Y N Have you been treated with antibiotics for other illnesses?
Y N Have you developed new allergies of any type as an adult?
Y N Have you had or do you have nail fungus [black nails]?
Y N Have you had or do you have prostatitis or vaginitis?
Y N Have you had or do you have frequent urinary tract infections?
Y N Have you had surgery?
Y N Have you taken or do you take steroids?
Y N Have you had or do you have crotch itch?
Y N Have you had or do you have a craving for sweets?
Y N Have you had or do you have a craving for deserts?
Y N Have you had or do you have a craving for sugar?
Y N Have you had or do you have a craving for Beer, Liquor, or wine?
Y N Have you had or do you have post nasal drip?
Y N Do you feel bloated after meals?
Y N Do you have excessive flatulence [gas] after meals?
Y N Have you had or do you have pressure behind your frontal sinuses?
Y N Have you had or do you have sinusitis [infection of the sinuses]?
Y N Have you had or do you have occasional wheezing?
Y N Do your symptoms worsen on humid / damp days?
Y N Do your symptoms worsen in moldy places?
Y N Have you had or do you have mood swings?
Y N Have you had or do you have poor or deteriorating memory?
Y N Have you had or do you have skin irritations?
Y N Have you had or do you have frequent tearing?
Y N Have you had or do you have frequent heart burn?
Y N Have you had or do you have occasional skin hives?
Y N Have you had or do you have psoriatic outbreaks?
Y N Have you had or do you have white spots on your tongue?
Y N Have you had or do you have anal itching?
Y N Have you had or do you have recurrent ear infections?
Y N Have you had or do you have burning eY ?
Y N Have you had or do you have chronic rashes?
Y N Have you had or do you have blisters in your inner mouth or tongue?
Y N Has your ability to concentrate diminished?
Y N Have you had or are currently being treated for Candida?
Y N Do you suffer from fatigue / lethargy?
Y N Do you crave rice, potatoes, fruits [raisins, watermelon