MEDICAL AND HEALTH HISTORY QUESTIONNAIRE

ADULT

● Please complete this form prior to your visit. Bring it with you the day of your visit. Please do not mail it!
● This questionnaire is an important part of your visit. Accurate completion of this form will assure that you
receive the best possible care in the time set aside for your visit.
● Please allow up to 60-90 minutes to complete this form. Please do not wait until the night before your visit.

PERSONAL INFORMATION:
Name Age Sex Marital Status

Address City Post Code

Home Phone Mobile Office E-mail

Birth date Occupation Past Occupation

Height Current weight

Name of spouse or partner Age Spouse’s Occupation

Children: Names, ages, gender

Ethnicity: Country of birth/arrival in NZ:

Name and phone of present GP

Who should we contact in case of emergency Phone Relationship

Who may we thank for referring you

FINANCIAL AGREEMENT AND CONSENT

I claim full financial responsibility for all services rendered at Golden Yogi. I understand that payment is required in full at the
time of service. I certify the information provided in this Health Assessment is correct to the best of my knowledge. I agree to
notify Golden Yogi of any changes with respect to the information provided in this form. I consent to medical evaluation and
treatment . I give permission to be contacted at the above numbers (including voicemail) for scheduling and office-patient
communication.

Signed X Date: Relationship to patient:

PRESENTING PROBLEMS OR SYMPTOMS:

PLEASE DESCRIBE YOUR MAJOR PROBLEMS OR SYMPTOMS. If none, please write your reason for seeking this
consultation. Please be clear and concise to help us help you. Include when the symptoms first appeared, the progression,
relieving facts, and previous treatments. Write what you can in the space provided; if you need more space, add a separate
sheet of paper.

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HAVE YOU SEEN OTHER PHYSICIANS FOR THESE PROBLEMS? Indicate the results of their evaluations:
Please bring recent medical records, blood tests, or hospital discharge summaries.

WHAT HABITS, ACTIVITIES, OR ATTITUDES DO YOU CONSIDER TO HAVE CONTRIBUTED TO ANY OF YOUR
PROBLEMS?

MEDICAL AND HEALTH HISTORY

PAST HISTORY
Did your mother have any problems during pregnancy with you? (Stress, illness, smoking, medications, alcohol)

Were you bottle or breast fed as an infant:

HOME LIFE AS A CHILD

􀁔 Loving 􀁔 Abusive 􀁔 Argumentative 􀁔 Friendly
􀁔 Supportive 􀁔 Peaceful 􀁔 Educational 􀁔 Single-parent
􀁔 Stressful 􀁔 Loud 􀁔 Alcoholic 􀁔 Lonely

Other comments:

CHILDHOOD ILLNESSES
Colic Allergies Rheumatic fever German measles

Bronchitis Eczema Recurrent colds Bedwetting

Asthma Pneumonia Ear infections Hyperactivity

􀁔Polio Meningitis Bronchitis Learning difficulties

Tonsillitis Other comments:

􀁔
PAST HISTORY
Using the Medical History category below please write down which apply to you in the box below:

MEDICAL HISTORY
Please circle if your family members including grandparents have ever had any of the following problems. Specify who.
Alcoholism Glandular fever
High cholesterol Rheumatic fever
Allergies Digestive disease
Asthma Rheumatoid disease
Eczema or psoriasis Herpes or shingles
Hayfever Sinus disease
Frequent infections Hypoglycemia
Anemia Strokes
Urinary infections Drug problems
Arthritis Thyroid problems
Lupus Tuberculosis
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Mental illness Heart disease
Depression Ulcers
Bleeding or bruising Hepatitis
Migraines High blood pressure
Cancer Weight problems
Pneumonia Comments:
Convulsions or epilepsy
Polio
Crohn’s disease or colitis
Prostate problems
Diabetes

PREVIOUS TESTS - Specify when, if known:

Last Physical Exam Kidney - bladder series
ECG Blood tests
X-rays Bone mineral density
GI series Angiogram – catheterization Mammogram
Gall bladder tests Other Tests or Comments:
Ultrasound tests

IMMUNIZATIONS / VACCINATIONS - Specify when, if known:

General: Flu Vaccinations (if yes, how often):

ANTIBIOTICS
Have you ever been on frequent or prolonged antibiotics?

HOSPITALIZATIONS
List major hospitalizations. Please give dates, locations, diagnoses, lengths of hospital stays, and surgeries.

NON-PRESCRIBED MEDICATIONS
List any laxatives, antacid, aspirin, antihistamines, decongestants, stimulants, etc.

PRESCRIBED MEDICATIONS
Name of drug and dose (BP meds, Inhalers, painkillers, sleeping pills, anti-depressants, oral contraceptive pill, etc)

ALLERGIES TO MEDICATIONS
Name or types of drug and reaction:

ALLERGIES AND SENSITIVITIES

Foods, Pollens, Animals, Chemicals, etc.

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 NUTRIENT SUPPLEMENTS
If you are taking vitamins, minerals, herbs, homeopathic remedies, or other supplements, please list them below. Be sure to
indicate the dose in milligrams or units, the brand, and the number of times taken per day. Try to bring the label of any
multiple or combination formulas.

Supplement Brand Dose # times per day .

LIFESTYLE:
Please be specific with your answers regarding types and quantities where requested

EXERCISE
Do you exercise regularly: Type(s) of exercise:

How often: Length of session: Do you sweat:

STRESS REDUCTION
Do you do any stress reduction or relaxation such as meditation, yoga, prayer, self-hypnosis, etc.?

How often: Length of session:

What level of stress do you consider yourself to be under? 􀁔 Low 􀁔 Medium 􀁔 High
What factors do you think influences your stress?

SLEEP
How many hours per night: Is it restful or restless: What time do you retire:

Do you wake during the night: Do you dream:

HOBBIES AND INTERESTS

What are your hobbies or other life interests?

SMOKING
Do you currently smoke? If yes how often:

Did you ever smoke? If yes how often and for what duration:

ALCOHOL
Specify what type of alcohol, amount and frequency

Do you drink to excess? Did you ever drink to excess? When did you stop?

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 RECREATIONAL DRUGS
Specify type and frequency (you may discuss privately)

NUTRITION

Please take the time to answer these questions specifically and concisely.
Specify what foods and beverages you normally consume during a typical day (Please be specific):

Weekdays Weekends Water/ Coffee/Tea/

Fluids Soft drinks
Breakfast

Snack

Lunch

Snack

Dinner

Snack

How long has this been your typical diet?

Do you eat regularly or irregularly: Do you binge or use food for rewards/escape:

If so, what foods/beverages do you use, and how often?

What foods would be most difficult for you to give up?

Do you have specific food cravings? What foods?

What work or scheduling considerations might create difficulties for you in trying to change your eating and other health
habits?

Are there any foods you avoid?

List any known food sensitivities / allergies:

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 GYNECOLOGICAL HISTORY

WOMEN
Date last period began: Date of last pelvic exams:
Date prior period began: Age at first period:
Date of last pap smear: Were the results normal:
Have you ever had an abnormal pap: When:
Results: Treatment:
Are you sexually active: Do you practice safe sex:
Are you trying to get pregnant: How long have you been trying:
Current birth control method: How long?
Past birth control methods?
Normally (not on pills) the number of days from the start of one period to the start of the next?
Number of days of flow?
Any bleeding between periods: When:
Any unusual pelvic pain, sensations, pressure or fullness:
Any unusual vaginal discharge or itching:
How long: Past treatment:
Any sexual concerns to discuss:
Any past history of tubal infection:
Any past history of sexually transmitted disease (STD)?
Have you ever had herpes: Venereal warts or papilloma virus?
Number of pregnancies: Dates of pregnancies:
Have you had any Miscarriages:
Describe any infertility problems:
Have you ever breastfed:
Have you ever had breast lumps:
Do you ever have nipple discharge:
Other?

MENSTRUAL SYMPTOMS
Check P for premenstrual; Check D for during the menstrual period; Check A for after menstrual period
P D A SYMPTOM P D A SYMPTOM
􀁔􀁔􀁔 Intermittent abdominal cramps 􀁔􀁔􀁔 Headaches
􀁔􀁔􀁔 Constant cramps 􀁔􀁔􀁔 Sugar/ Food cravings
􀁔􀁔􀁔 Low back pains 􀁔􀁔􀁔 Depression
􀁔􀁔􀁔 Pressure sensations 􀁔􀁔􀁔 Irritability
􀁔􀁔􀁔 Breast tenderness 􀁔􀁔􀁔 Acne
􀁔􀁔􀁔 Mood swings 􀁔􀁔􀁔 Other:
How severe are the symptoms:

What treatments have you tried:

MEN
Male Reproductive
Libido / Sexual dysfunction
Impotence
Hernia
Prostate examination?
Testicular examination?

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 BODY SYSTEM REVIEW
Tick C for current problem; Tick I for intermittent problem; Tick P for past problem
C I P Symptoms Section reserved for Practitioners notes

􀁔 􀁔 􀁔 Digestive
􀁔 􀁔 􀁔 Dental problems or decay
􀁔 􀁔 􀁔 Sore/ bleeding gums or tongue
􀁔 􀁔 􀁔 Loss of taste or smell
􀁔 􀁔 􀁔 Sores in or around mouth
􀁔 􀁔 􀁔 Difficulty swallowing (Dysphagia)
􀁔 􀁔 􀁔 Recurring indigestion
􀁔 􀁔 􀁔 Nausea or vomiting
􀁔 􀁔 􀁔 Intestinal gas or flatulence
􀁔 􀁔 􀁔 Belching / Reflux
􀁔 􀁔 􀁔 Bloating
􀁔 􀁔 􀁔 Abdominal pain or cramps
􀁔 􀁔 􀁔 Constipation
􀁔 􀁔 􀁔 Diarrhea or loose stools
􀁔 􀁔 􀁔 Rectal itching
􀁔 􀁔 􀁔 Haemorrhoids
􀁔 􀁔 􀁔 Blood with stools
􀁔 􀁔 􀁔 Pain with passing bowel motion
􀁔 􀁔 􀁔 Black stools
􀁔 􀁔 􀁔 Diverticulitis or diverticulosis
􀁔 􀁔 􀁔 Loss of appetite
􀁔 􀁔 􀁔 Constant hunger
􀁔 􀁔 􀁔 Parasites
􀁔 􀁔 􀁔 Traveller’s Diarrhea

Liver
Jaundice
Hepatitis or pancreatitis
Acid reflux

Endocrine
􀁔 􀁔 􀁔 Feel excessively warm
􀁔 􀁔 􀁔 Feel excessively cold
􀁔 􀁔 􀁔 Weight loss/ gain
􀁔 􀁔 􀁔 Diabetes
Low Blood Sugars
Night sweats
Hot Flashes
Fatigue/ constant low energy
Hypothyroid (low)
Hyperthyroid (high)

Urinary
􀁔 􀁔 􀁔 Freq/Urgency
􀁔 􀁔 􀁔 Colour (Brown or red urine)
􀁔 􀁔 􀁔 Pain on urination
􀁔 􀁔 􀁔 Blood in urine
􀁔 􀁔 􀁔 Prostate Nocturia
􀁔 􀁔 􀁔 Loin Pain
􀁔 􀁔 􀁔 Diff. Start/stop or Incontinence
􀁔 􀁔 􀁔 Kidney or bladder infection
Recurrent Urinary Tract Infections

Cardiovascular
􀁔 􀁔 􀁔 Heart murmur
􀁔 􀁔 􀁔 High blood pressure
􀁔 􀁔 􀁔 Low Blood pressure
􀁔 􀁔 􀁔 Skipped heartbeats
􀁔 􀁔 􀁔 Racing heart
􀁔 􀁔 􀁔 Chest pain or pressure
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􀁔 􀁔 􀁔 Swollen feet or ankles (Oedema)
􀁔 􀁔 􀁔 Difficulty breathing at night
Varicose veins

Respiratory
􀁔 􀁔 􀁔 Sinus or nasal congestion
􀁔 􀁔 􀁔 Runny nose
􀁔 􀁔 􀁔 Frequent colds
􀁔 􀁔 􀁔 Nasal polyps
􀁔 􀁔 􀁔 Sore throats
􀁔 􀁔 􀁔 Swollen glands
􀁔 􀁔 􀁔 Recurrent fevers or chills
􀁔 􀁔 􀁔 Shortness of breath
􀁔 􀁔 􀁔 Wheezing or gasping
􀁔 􀁔 􀁔 Coughing
􀁔 􀁔 􀁔 Coughing blood
􀁔 􀁔 􀁔 Chest colds or pneumonia
Immune
􀁔 􀁔 􀁔 Frequent colds/coughs
􀁔 􀁔 􀁔 Glandular Fever
Herpes/ Cold sores
Other recurrent infections
Nervous
􀁔 􀁔 􀁔 Sleep (Onset/maintenance)
􀁔 􀁔 􀁔 Headache
􀁔 􀁔 􀁔 Migraine
􀁔 􀁔 􀁔 Visual Disturbances
􀁔 􀁔 􀁔 Dizziness/Vertigo
􀁔 􀁔 􀁔 Blackouts or fainting
􀁔 􀁔 􀁔 Loss of balance
􀁔 􀁔 􀁔 Memory loss
􀁔 􀁔 􀁔 Anxiety/nervousness
􀁔 􀁔 􀁔 Stress
􀁔 􀁔 􀁔 Depression
􀁔 􀁔 􀁔 Suicidal thoughts
􀁔 􀁔 􀁔 Sought psychological help
􀁔 􀁔 􀁔 Epilepsy
􀁔 􀁔 􀁔 Trembling or tremors
Musculoskeletal
􀁔 􀁔 􀁔 Osteoporosis
􀁔 􀁔 􀁔 Aching muscles or joints
􀁔 􀁔 􀁔 Arthritis (Osteo / Rheum)
􀁔 􀁔 􀁔 Joint stiffness
􀁔 􀁔 􀁔 Back or neck pain
􀁔 􀁔 􀁔 Weakness
􀁔 􀁔 􀁔 Painful feet
􀁔 􀁔 􀁔 Leg cramps
􀁔 􀁔 􀁔 Injuries
Skin
􀁔 􀁔 􀁔 Dry / Oily
􀁔 􀁔 􀁔 Acne
􀁔 􀁔 􀁔 Eczema
􀁔 􀁔 􀁔 Psoriasis
􀁔 􀁔 􀁔 Dandruff or seborrhea
􀁔 􀁔 􀁔 Rashes / Itching or burning skin
􀁔 􀁔 􀁔 Hives
􀁔 􀁔 􀁔 Dermatitis
􀁔 􀁔 􀁔 Fungal
􀁔 􀁔 􀁔 Herpes – cold sores
􀁔 􀁔 􀁔 Moles
􀁔 􀁔 􀁔 Numbness or tingling
􀁔 􀁔 􀁔 Easy bruising
Eyes / Sight
􀁔 􀁔 􀁔 Blurry vision
􀁔 􀁔 􀁔 Double vision
􀁔 􀁔 􀁔 Cataracts
􀁔 􀁔 􀁔 Eye pain or itching
􀁔 􀁔 􀁔 Watering eyes or redness

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 Ears
􀁔 􀁔 􀁔 Hearing difficulties / loss
􀁔 􀁔 􀁔 Earaches or drainage
􀁔 􀁔 􀁔 Noises or ringing in ears
􀁔 􀁔 􀁔 Recurrent ear infections

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