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Case History: Please Include Approximate Dates Wherever Possible

This document is a case history form for a new patient. It collects extensive personal and medical information including symptoms, illnesses, surgeries, medications, family history, lifestyle factors and areas of pain or discomfort.

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adolfomc2001
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We take content rights seriously. If you suspect this is your content, claim it here.
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32 views

Case History: Please Include Approximate Dates Wherever Possible

This document is a case history form for a new patient. It collects extensive personal and medical information including symptoms, illnesses, surgeries, medications, family history, lifestyle factors and areas of pain or discomfort.

Uploaded by

adolfomc2001
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CASE HISTORY

Please include approximate dates wherever possible.


Return to:

Full Name
Address

Telelephone Mobile
Email address
Date and place of birth:
Age Occupation
Marital status Children
Introduced by
Symptoms

Date of onset
Sudden/Gradual
Medical diagnosis – please include dates

Treatment you have had for the present complaint – please include dates

Complaint made worse by

Complaint eased by
1
Falls and accidents – including dates

Serious illnesses – including dates

Surgery - please include approximate dates

Previous natural therapeutic treatments:

Have you had any of the following? If so, list and give approximate dates
X-Rays

Inoculations

Last medical examination date


Blood transfusions, number of units received, and dates.

Have you ever suffered from:


Asthma Migraine
Bronchitis Mumps
Chicken pox Pneumonia
Cystitis/urethritis Rheumatic fever
German measles Scarlet fever
Jaundice Tuberculosis
Malaria Venereal disease
Measles Whooping cough

2
Do you now suffer from:
Any allergies Varicose veins
Insomnia Constipation
Lack/excess of appetite Diarrhea

If so name the remedy used

Have you ever taken any of the following? If so, specify the actual drug if possible:
Antibiotics Tranquillizers
Quinine Sleeping tablets
Anti-malarial drugs Pep pills
Steroids Hormone replacements
Tonics Cortisone
Barbiturates Social drugs
Vitamins Contraceptive Pill

What medicines (if any) are you taking now?

Have any of your relatives suffered from:


Asthma Kidney problems
Cancer Neurosis
Diabetes Mental trouble
Excema Rheumatic Fever
Epilepsy Tuberculosis
Heart trouble Arthritis

Any general comments you feel may be important and relevant to your health:

Height Weight
3
Blood Pressure: High/Low
Temperament and personality characteristics:

Recreational or other interests:

Daily intake of: Alcohol Cigarettes/tobacco


Comments on your diet, including daily fluid intake (other than alcohol):

Religion, Spiritual Faith or Practise/ Philosophy of Life:

Please use the diagrams to indicate and/or describe any areas of pain or discomfort:
Use ‘Insert’: ‘Illustrations’ : ‘Shapes’ to highlight areas on the diagrams

Req
Sent
4 Rec

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