MARSHALL THOMPSON HEALTH

Holistic, Integrative, Functional Health Consulting & Athletic  Performance Training

Marshall Thompson, CNHP, BANT, CPT, 

MovNat Trainer level II, SpartanSGX Coach

720-248-7767

info@marshallthompsonhealth.com

 

 

HEALTH HISTORY QUESTIONNAIRE

Name
Name
Date of First Visit
Date of First Visit
Address
Address
Telephone # (home)
Telephone # (home)
Telephone # (cell)
Telephone # (cell)
Telephone # (work)
Telephone # (work)
Fax
Fax
Gender
Date of Birth
Date of Birth
Born at:
Were you breastfed?
Whom do you live with?
Grandparents - health
Grandparents - check all that apply:
Father - health
Father - check all that apply
Mother - health
Mother - check all that apply
Brother(s) - health
Brother(s) - check all that apply
Sister(s) - health
Sister(s) - check all that apply
Spouse - health
Spouse - check all that apply
Child(ren) - health
Child(ren) - check all that apply
On your father's side of the family:
Childhood Illnesses - Scarlet Fever
Yes = conditions you have NOW No = conditions you NEVER had Previously = conditions you PREVIOUSLY had
Childhood Illnesses - Mumps
Childhood Illnesses - Chicken Pox
Childhood Illnesses - Diptheria
Childhood Illnesses - Measles
Childhood Illnesses - Rheumatic Fever
Childhood Illnesses - German Measles
Electrocardiogram
Electroencephalogram
Immunizations - Polio
Immunizations - Pertussis
Immunizations - Tetanus
Immunizations - Diphtheria
Immunizations - Measles/Mumps/Rubella
Immunizations - Hepatitis
Allergies and/or Sensitivities - List each item that you are hypersensitive or or allergic to.
Allergies and/or Sensitivities - List each item that you are hypersensitive or or allergic to.
Allergies and/or Sensitivities - List each item that you are hypersensitive or or allergic to.
Allergies and/or Sensitivities - List each item that you are hypersensitive or or allergic to.
Allergies and/or Sensitivities - List each item that you are hypersensitive or or allergic to.
Do you take or use Laxatives?
Current & past medications
Do you take or use Cortisone?
Current & past medications
Do you take or use Tranquilizers?
Current & past medications
Do you take or use Pain Relievers?
Do you take or use Appetite Suppressants?
Do you take or use Thyroid Medication?
Current & past medications
Do you take or use Antacids?
Current & past medications
Do you take or use Antibiotics?
Current & past medications
Do you take or use Sleeping Pills?
Current & past medications
Do you exercise?
Average 6 - 8 hours of sleep?
Do you sleep well?
Awaken when rested?
Have dreams?
Spend time outside?
Have a history of abuse?
Choose type of abuse:
Physical Emotional Verbal Sexual
Any major traumas?
Do you avoid canola oil?
Do you avoid cholesterol?
Yes No Previously
Do you avoid saturated fat?
Do you avoid hydrogenated oils?
Do you avoid calories?
Do you add salt?
Do you eat three meals a day?
Do you eat out often?
Do you go on diets often?
Consume artificial sweeteners?
Do you drink coffee?
Do you drink black or green tea?
Do you drink cola or other sodas?
Do you consume artificial colors?
Enjoy your work?
Take vacations?
Have a supportive relationship?
Watch television?
Do you regularly read?
Do you carry a cell phone or other wireless device on your person regularly?
Where do you carry your cell phone or other wireless device?
Check all that apply
Use alcoholic beverages?
Treated for alcoholism?
Any other drug use?
Do you use tobacco?
Smoked previously?
Use of chemical fertilizers, pesticides or herbicides at home/apt. complex?
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Use a microwave? (select most accurate)
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
Household, Yard, Bodycare, Other
General
General
General
General
General
General
General
Treated for emotional issues?
Review of systems: Mental/Emotional
Mood swings?
Review of systems: Mental/Emotional
Considered/attempted suicide?
Review of systems: Mental/Emotional
Poor concentration?
Review of systems: Mental/Emotional
Depression?
Review of systems: Mental/Emotional
Anxiety or nervousness?
Review of systems: Mental/Emotional
Low motivation?
Review of systems: Mental/Emotional
Memory problems?
Review of systems: Mental/Emotional
Review of systems: Mental/Emotional
Hypothyroid?
Review of systems: Endocrine
Heat intolerance?
Review of systems: Endocrine
Cold intolerance?
Review of systems: Endocrine
Seasonal depression?
Review of systems: Endocrine
Review of systems: Endocrine
Fatigue?
Review of systems: Endocrine
Hypoglycemia?
Review of systems: Endocrine
Diabetes?
Review of systems: Endocrine
Excessive thirst?
Review of systems: Endocrine
Excessive hunger?
Review of systems: Endocrine
Review of systems: Endocrine
Review of systems: Endocrine
Vaccinations?
Review of systems: Immune
Chronic Fatigue Syndrome?
Review of systems: Immune
Chronically swollen glands?
Review of systems: Immune
Reactions to vaccinations?
Review of systems: Immune
Chronic infections?
Review of systems: Immune
Slow wound healing?
Review of systems: Immune
Review of systems: Immune
Seizures?
Review of systems: Neurological
Muscle weakness?
Review of systems: Neurological
Loss of memory?
Review of systems: Neurological
Select frequency:
Review of systems: Neurological
Vertigo or dizziness?
Review of systems: Neurological
Paralysis?
Review of systems: Neurological
Numbness or tingling?
Review of systems: Neurological
Easily stressed?
Review of systems: Neurological
Strange tastes/smells?
Review of systems: Neurological
Loss of balance?
Review of systems: Neurological
Review of systems: Neurological
Easy bleeding?
Review of systems: Blood/Peripheral Vascular
Easy bruising?
Review of systems: Blood/Peripheral Vascular
Deep leg pain in calves?
Review of systems: Blood/Peripheral Vascular
Varicose veins?
Review of systems: Blood/Peripheral Vascular
Anemia?
Review of systems: Blood/Peripheral Vascular
Blood clots?
Review of systems: Blood/Peripheral Vascular
Cold hands?
Review of systems: Blood/Peripheral Vascular
Cold feet?
Review of systems: Blood/Peripheral Vascular
Rashes, eczema, psoriasis?
Review of systems: Skin
Acne/boils?
Review of systems: Skin
Color change?
Review of systems: Skin
Lumps?
Review of systems: Skin
Hives?
Review of systems: Skin
Itching?
Review of systems: Skin
Perpetual hair loss?
Review of systems: Skin
Excessive perspiration?
Review of systems: Skin
Review of systems: Skin
Headaches?
Review of systems: Head
Migraines?
Review of systems: Head
Head Injury?
Review of systems: Head
Jaw/TMJ problems?
Review of systems: Head
Review of systems: Head
"Floaters" in eyes?
Review of systems: Eyes
Impaired vision?
Review of systems: Eyes
Blurring?
Review of systems: Eyes
Color blindness?
Review of systems: Eyes
Double vision?
Review of systems: Eyes
Cataracts?
Review of systems: Eyes
Select:
Review of systems: Eyes
Eye pain/strain?
Review of systems: Eyes
Tearing or dryness?
Review of systems: Eyes
Glaucoma?
Review of systems: Eyes
Review of systems: Ears
Impaired hearing?
Review of systems: Ears
Earaches?
Review of systems: Ears
Ringing?
Review of systems: Eyes
Dizziness?
Review of systems: Ears
Review of systems: Ears
Frequent colds?
Review of systems: Nose/Sinuses
Stuffiness?
Review of systems: Nose/Sinuses
Sinus infections?
Review of systems: Nose/Sinuses
Nose bleeds?
Review of systems: Nose/Sinuses
Hay fever/allergies?
Review of systems: Nose/Sinuses
Loss of smell or taste?
Review of systems: Nose/Sinuses
Other
Review of systems: Nose/Sinuses
Frequent sore throat?
Review of systems: Mouth/Throat
Gum problems?
Review of systems: Mouth/Throat
Teeth grinding?
Review of systems: Mouth/Throat
Dental cavities?
Review of systems: Mouth/Throat
Profuse saliva?
Review of systems: Mouth/Throat
Sore tongue/lips?
Review of systems: Mouth/Throat
Hoarseness/often clearing throat?
Review of systems: Mouth/Throat
Mercury fillings?
Review of systems: Mouth/Throat
Review of systems: Mouth/Throat
Lumps?
Review of systems: Neck
Goiter?
Review of systems: Neck
Swollen glands/lymph nodes?
Review of systems: Neck
Pain or stiffness?
Review of systems: Neck
Review of systems: Neck
Cough?
Review of systems: Respiratory
Sputum?
Review of systems: Respiratory
Spitting up blood?
Review of systems: Respiratory
Asthma?
Review of systems: Respiratory
Pneumonia?
Review of systems: Respiratory
Emphysema?
Review of systems: Respiratory
Pain on breathing?
Review of systems: Respiratory
Tuberculosis?
Review of systems: Respiratory
Shortness of breath lying down?
Review of systems: Respiratory
Wheezing?
Review of systems: Respiratory
Bronchitis?
Review of systems: Respiratory
Pleurisy?
Review of systems: Respiratory
Difficulty in breathing?
Review of systems: Respiratory
Shortness of breath?
Review of systems: Respiratory
Shortness of breath at night?
Review of systems: Respiratory
Shortness of breath on exertion?
Review of systems: Respiratory
Review of systems: Respiratory
Heart disease?
Review of systems: Cardiovascular
High blood pressure?
Review of systems: Cardiovascular
Low blood pressure?
Review of systems: Cardiovascular
Blood clots?
Review of systems: Cardiovascular
Phlebitis (vein inflammation)?
Review of systems: Cardiovascular
Rheumatic fever?
Review of systems: Cardiovascular
High cholesterol?
Review of systems: Cardiovascular
Stroke?
Review of systems: Cardiovascular
Angina?
Review of systems: Cardiovascular
Murmurs?
Review of systems: Cardiovascular
Swelling in ankles?
Review of systems: Cardiovascular
Fainting?
Review of systems: Cardiovascular
Heart palpitations/fluttering?
Review of systems: Cardiovascular
Chest pain?
Review of systems: Cardiovascular
Heart attack?
Review of systems: Cardiovascular
Aneurysm?
Review of systems: Cardiovascular
Review of systems: Cardiovascular
Trouble swallowing?
Review of systems: Gastrointestinal
Increase in thirst?
Review of systems: Gastrointestinal
Decrease in thirst?
Review of systems: Gastrointestinal
Nausea?
Review of systems: Gastrointestinal
Vomiting?
Review of systems: Gastrointestinal
Vomiting up blood?
Review of systems: Gastrointestinal
Pain or cramps?
Review of systems: Gastrointestinal
Belching?
Review of systems: Gastrointestinal
Passing gas?
Review of systems: Gastrointestinal
Mucus in the stool?
Review of systems: Gastrointestinal
Review of systems: Gastrointestinal
Jaundice (yellow skin)?
Review of systems: Gastrointestinal
Liver disease?
Review of systems: Gastrointestinal
Heartburn?
Review of systems: Gastrointestinal
Increase in appetite?
Review of systems: Gastrointestinal
Decrease in appetite?
Review of systems: Gastrointestinal
Review of systems: Gastrointestinal
Review of systems: Gastrointestinal
Constipation?
Review of systems: Gastrointestinal
Diarrhea?
Review of systems: Gastrointestinal
Blood in the stool?
Review of systems: Gastrointestinal
Undigested food in the stool?
Review of systems: Gastrointestinal
Gall bladder disease?
Review of systems: Gastrointestinal
Ulcers?
Review of systems: Gastrointestinal
Hemorrhoids?
Review of systems: Gastrointestinal
Review of systems: Gastrointestinal
Pain on urination?
Review of systems: Urinary
Review of systems: Urinary
Frequent infections?
Increased urgency or frequency?
Review of systems: Urinary
Inability to hold urine?
Review of systems: Urinary
Kidney stones?
Review of systems: Urinary
Hernias?
Review of systems: Males
Testicular pain?
Review of systems: Males
Prostate disease?
Review of systems: Males
Are you sexually active?
Review of systems: Males
Pain during intercourse?
Review of systems: Males
Premature ejaculation?
Review of systems: Males
Impotence?
Review of systems: Males
Herpes?
Review of systems: Males
Testicular masses?
Review of systems: Males
Do you do testicle self-exams?
Review of systems: Males
Low sexual desire?
Review of systems: Males
Discharge or sores?
Review of systems: Males
Chlamydia?
Review of systems: Males
Gonorrhea?
Review of systems: Males
Condyloma?
Review of systems: Males
Syphilis?
Review of systems: Males
Review of systems: Males
Review of systems: Females
Review of systems: Females
Review of systems: Females
Review of systems: Females
Heavy or excessive flow?
Review of systems: Females
PMS?
Review of systems: Females
Review of systems: Females
Review of systems: Females
Ovarian cysts?
Review of systems: Females
Endometriosis?
Review of systems: Females
Low sexual desire?
Review of systems: Females
Are you sexually active?
Review of systems: Females
Gonorrhea?
Review of systems: Females
Herpes?
Review of systems: Females
Chlamydia?
Review of systems: Females
Condyloma?
Review of systems: Females
Syphilis?
Review of systems: Females
Are cycles regular?
Review of systems: Females
Bleeding between cycles?
Review of systems: Females
Pain during intercourse?
Review of systems: Females
Clotting?
Review of systems: Females
Discharge?
Review of systems: Females
Birth control?
Review of systems: Females
Review of systems: Females
Review of systems: Females
Review of systems: Females
Review of systems: Females
Review of systems: Females
Difficulty conceiving?
Review of systems: Females
Menopausal symptoms?
Review of systems: Females
Abnormal PAP?
Review of systems: Females
Cervical dysplasia?
Review of systems: Females
Do you do breast self-exams?
Review of systems: Females
Breast lumps?
Review of systems: Females
Breast pain/tenderness?
Review of systems: Females
Nipple discharge?
Review of systems: Females
Inverted nipples?
Review of systems: Females
Review of systems: Females
Joint pain/stiffness (please specify below)
Review of systems: Musculoskeletal
Left Hand (1-5) - Joint pain/stiffness
Review of systems: Musculoskeletal
Right Hand (fingers: 1-5) - Joint pain/stiffness
Review of systems: Musculoskeletal
Left Foot (1-5) - Joint pain/stiffness
Review of systems: Musculoskeletal
Right Foot (1-5) - Joint pain/stiffness
Review of systems: Musculoskeletal
Appendages
Review of systems: Musculoskeletal
Broken bones?
Review of systems: Musculoskeletal
Muscle spasms or cramps?
Review of systems: Musculoskeletal
Arthritis?
Review of systems: Musculoskeletal
Muscular pain or weakness?
Review of systems: Musculoskeletal
Sciatica?
Review of systems: Musculoskeletal
Review of systems: Musculoskeletal
Is there anything else you would like us to know about regarding your health?