medical history form Medical History Please fill in this information as fully as possible as it will help accurate diagnosis and lead to a better treatment. THIS INFORMATION IS TREATED AS CONFIDENTIAL Name* First Last Email* Phone*Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Height* Weight* Main complaint:*Secondary complaints:G.P.s diagnosis/WM diagnoses:Any problems during your birth or during your mother’s pregnancy?Vaccinations: Any reactions? Any unusual vaccinations?Illnesses: Please list any surgery, accidents, or reasons for other hospital/regular GP visits, and note approximate age. Also make a note of any scars from accidents or operations. Childhood Illnesses:Adolescent Illnesses:Adulthood Illnesses:Please list any major illnesses in your immediate family (parents, siblings and grandparents) e.g cancer, diabetes, heart disease, blood pressure, blood disorders, neurological problems, psychological problems etcFamily illnesses:Please list any muscular-skeletal problems which bother you now or affected you in the past: Please tick any symptoms you have now. Please underline problems which you have been affected by in the past. SkinCurrent Skin Symptoms: eczema acne psoriasis rashes dermatitis boils fungal infections warts Past Skin Symptoms: eczema acne psoriasis rashes dermatitis boils fungal infections warts Gastro-intestinalCurrent Gastro-intestinal (GI) symptoms: constipation diarrhoea no appetite stomach pain indigestion heartburn intestinal gas belching ulcer gastritis lack of stomach acid haemorrhoids ileo-caecal valve spasm peritonitis pancreatitis irritable bowel polyps GI tumours Past Gastro-intestinal (GI) symptoms: constipation diarrhoea no appetite stomach pain indigestion heartburn intestinal gas belching ulcer gastritis lack of stomach acid haemorrhoids ileo-caecal valve spasm peritonitis pancreatitis irritable bowel polyps GI tumours RespiratoryCurrent Respiratory Symptoms: asthma emphysema bronchitis cough wheeze pneumonia lung absces Past Respiratory Symptoms: asthma emphysema bronchitis cough wheeze pneumonia lung absces HormonalCurrent Hormonal imbalance: under-active thyroid over-active thyroid diabetes hypoglycaemia other imbalance stated below Other hormonal imbalance ? Past Hormonal imbalance: under-active thyroid over-active thyroid diabetes hypoglycaemia other imbalance stated below Other past hormonal imbalance ? Gender SpecificCurrent Male Symptoms impotence premature ejaculation prostate problems vasectomy infertility Past Male Symptoms impotence premature ejaculation prostate problems vasectomy infertility Current Female Symptoms menstrual problems cramping heavy/light/irregular periods PMS overemotional reactions menopause symptoms tubal ligation infertility low libido Past Female Symptoms menstrual problems cramping heavy/light/irregular periods PMS overemotional reactions menopause symptoms tubal ligation infertility low libido AutoimmuneCurrent Autoimmune and inflammatory conditions: Hashimoto’s disease (thyroid) rheumatism lupus colitis Crohn’s disease alopecia (baldness) allergies food allergy cellulitis atopic dermatitis neurodermatitis sinus allergy vulvitis low immunity Past Autoimmune and inflammatory conditions: Hashimoto’s disease (thyroid) rheumatism lupus colitis Crohn’s disease alopecia (baldness) allergies food allergy cellulitis atopic dermatitis neurodermatitis sinus allergy vulvitis low immunity Focal infectionsCurrent effects of focal infection: rheumatic disease rheumatic fever arthritis skin disease Past effects of focal infection: rheumatic disease rheumatic fever arthritis skin disease Tissue or ligamentsCurrent connective tissue or ligament disease: myofascial pain syndrome fibromyalgia tendinitis pericarditis constant slight fever glomerulonephritis plantar fasciitis scarlet fever staphylococci/streptococci infections ear infections easily catch sore throat or colds swollen glands Past connective tissue or ligament disease: myofascial pain syndrome fibromyalgia tendinitis pericarditis constant slight fever glomerulonephritis plantar fasciitis scarlet fever staphylococci/streptococci infections ear infections easily catch sore throat or colds swollen glands ENTCurrent Ear nose throat infections: tinnitus (ringing in ear) itchy ear ear pain frequent ear infections deafness sinus head aches constant sinus congestion yellow mucus stuffy nose post-nasal drip dry throat itchy throat strep throat infections sore throat Past Ear nose throat infections: tinnitus (ringing in ear) itchy ear ear pain frequent ear infections deafness sinus head aches constant sinus congestion yellow mucus stuffy nose post-nasal drip dry throat itchy throat strep throat infections sore throat Oral disease:Present Oral symptoms bleeding gums periodontitis dental abscess mumps stomatitis (mouth inflammation) TMJ toothaches without cavities Past Oral symptoms bleeding gums periodontitis dental abscess mumps stomatitis (mouth inflammation) TMJ toothaches without cavities General SymptomsGeneral present insomnia exhaustion emotional problems difficulty concentrating on a task easily car/sea/air sick no appetite for breakfast moody in mornings unusual sweating or never sweat Before noon: no energy feel spacey scattered mind hate to wake early but energetic in evening long shower or bath makes you feel dizzy / faint General past insomnia exhaustion emotional problems difficulty concentrating on a task easily car/sea/air sick no appetite for breakfast moody in mornings unusual sweating or never sweat Before noon: no energy feel spacey scattered mind hate to wake early but energetic in evening long shower or bath makes you feel dizzy / faint Medication & DrugsCurrent medication Birth control pill tobacco alcohol cocaine marijuana other. Prescription drugs (dose) herbs minerals supplements Past medication Birth control pill tobacco alcohol cocaine marijuana other. Prescription drugs (dose) herbs minerals supplements Other symptoms: Δ