MARSHALL THOMPSON HEALTH

Holistic, Integrative, Functional Health Consulting & Athletic  Performance Training

Marshall Thompson, CNHP, BANT, CPT, 

MovNat Trainer level II, SpartanSGX*D Coach

720-248-7767

info@marshallthompsonhealth.com

 

 

SHORT HEALTH HISTORY QUESTIONNAIRE

Name *
Name
Date of First Visit *
Date of First Visit
Address
Address
Telephone # (home)
Telephone # (home)
Telephone # (cell)
Telephone # (cell)
Gender *
Date of Birth *
Date of Birth
What is your primary goal?
Average how many hours of Actual sleep?
Do you sleep well?
Awaken when rested?
Have dreams?
Spend time outside?
Do you eat three meals a day?
Do you drink coffee?
Do you drink black or green tea?
Do you drink cola or other sodas?
Do you consume artificial colors?
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?
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
General
General
General
General
General
General
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 hunger?
Review of systems: Endocrine
Review of systems: Endocrine
Review of systems: Endocrine
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
Muscle weakness?
Review of systems: Neurological
Vertigo or dizziness?
Review of systems: Neurological
Numbness or tingling?
Review of systems: Neurological
Easily stressed?
Review of systems: Neurological
Strange tastes/smells?
Review of systems: Neurological
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
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
Review of systems: Skin
Headaches?
Review of systems: Head
Migraines?
Review of systems: Head
Head Injury?
Review of systems: Head
Impaired vision?
Review of systems: Eyes
Color blindness?
Review of systems: Eyes
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
Frequent sore throat?
Review of systems: Mouth/Throat
Teeth grinding?
Review of systems: Mouth/Throat
Dental cavities?
Review of systems: Mouth/Throat
Dental fillings?
Review of systems: Mouth/Throat
Swollen glands/lymph nodes?
Review of systems: Neck
Pain or stiffness?
Review of systems: Neck
Asthma?
Review of systems: Respiratory
Shortness of breath?
Review of systems: Respiratory
High blood pressure?
Review of systems: Cardiovascular
Low blood pressure?
Review of systems: Cardiovascular
Swelling in ankles?
Review of systems: Cardiovascular
Review of systems: Gastrointestinal
Constipation?
Review of systems: Gastrointestinal
Diarrhea?
Review of systems: Gastrointestinal
Ulcers?
Review of systems: Gastrointestinal
Pain on urination?
Review of systems: Urinary
Frequent infections?
Ovarian cysts?
Review of systems: Females
Endometriosis?
Review of systems: Females
Low sexual desire?
Review of systems: Females
Are cycles regular?
Review of systems: Females
Bleeding between cycles?
Review of systems: Females
Birth control?
Review of systems: Females
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?