vitae health history form adult

ADULT HEALTH HISTORY FORM

© VITAE HEALTH® PTY LTD – 2007-2013

Engage in Life Inc. ™. Not to be copied, reprinted or redistributed without expressed permission ©1994-2010 of 6

Your Name:

Today’s Date: Date of Birth:

Please indictae how you discovered Vitae Health …

q Family member q Friend q Marketing/Advertising

q Signage q Professional q Website/Google

Please name the person who has recommended that you see us:

Welcome to Vitae Health - where our aim is to listen, to understand and to help you thrive on your journey in life.

Completion of this form provides us with an improved understanding of your physical, emotional and chemical stresses that can gradually overwhelm the body and contribute to other health problems.

Please complete this form as thoroughly as possible. Information collected and discussed on this form is strictly confidential and can only be shared with your consent.

Please tick the purpose for your visit: Please tick (þ) all appropriate

q To achieve symptomatic relief or crisis management q To improve health and brain organisation q To achieve peak performance and wellness q Other: ______________________________________

q If this assessment is only to ensure you are as healthy as possible and functioning at

your maximum potential, please tick this box. (Then go to Section C)

Please continue over …




(A) What is the main reason for this visit? (Note: There will be room over the page for other reasons)

__________________________________________________________________________________________________

__________________________________________________________________________________________________

If pain is involved, please fill in this box.

• Rank the amount of pain on a scale of 1 to 10 (1 is minimal, 10 is extreme)

(Right now) (At its worst)

• Describe its character? Please tick (þ) all appropriate

q Sharp q Dull ache q Burning q Tingling q Throbbing q Spasms q Other ___________________________

• Please indicate on the image the location of the problem …

• When did you first notice it? ______________________________________________________________

• What happened? ______________________________________________________________

• How often does it occur? ______________________________________________________________

• What relieves it? ______________________________________________________________

• What aggravates it? ______________________________________________________________

• Other professionals seen for this _______________________________________________________

• Treatment and results ______________________________________________________________

• Is the problem worse during a certain time of the day? q Yes q No

(If yes when) ________________________________________________________________________________________________

• Does this interfere with your sleep? q Yes q No

• Does this interfere with your eating? q Yes q No

• Does this interfere with your daily routine? q Yes q No

• Is this becoming worse? q Yes q No




(B) What is the secondary reason for this visit?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

If pain is involved, please fill in this box.

• Rank the amount of pain on a scale of 1 to 10 (1 is minimal, 10 is extreme)

(Right now) (At its worst)

• Describe its character? Please tick (þ) all appropriate

q Sharp q Dull ache q Burning q Tingling q Throbbing q Spasms q Other ___________________________

• Please indicate on the image the location of the problem …

• When did you first notice it? ______________________________________________________________

• What happened? ______________________________________________________________

• How often does it occur? ______________________________________________________________

• What relieves it? ______________________________________________________________

• What aggravates it? ______________________________________________________________

• Other professionals seen for this _______________________________________________________

• Treatment and results ______________________________________________________________

• Is the problem worse during a certain time of the day? q Yes q No

(If yes when) ________________________________________________________________________________________________

• Does this interfere with your sleep? q Yes q No

• Does this interfere with your eating? q Yes q No

• Does this interfere with your daily routine? q Yes q No

• Is this becoming worse? q Yes q No




(C) Do you have, or have you had, any of the following?

Please note all other health concerns present or in the past. Please tick (þ) all appropriate

q Allergies q Anxiety q Asthma q Bleeding disorders q Bloating q Brain Fog q Bronchitis q Cancer q Cataracts q Constipation q Depression q Diabetes q Difficult digestion q Difficulty concentrating q Difficulty sleeping q Dizziness q Ear infections q Epilepsy q Fatigue q Fears q Fertility problems q Fibromyalgia q Frequent colds/flu q Headaches

q Hearing loss q Heart disease q Heart palpitations q Heartburn q Herniated disc q High cholesterol q Hypertension q Indigestion q Irritable bowel q Light-headedness q Loose stools q Low energy q Lowered immunity q Memory problems q Menstrual irregularity q Menstrual pain/cramping q Migraines q Moodiness q Numbness/tingling q Osteoarthritis q Osteoporosis q Pain (back) q Pain (jaw) q Pain (knee/hip/foot)

q Pain (neck) q Pain (shoulder/arm) q Pins and needles q PMS q Pneumonia q Poor balance q Restless sleep q Seizures q Sleep apnoea q Stress q Stroke q Temper q Thyroid problems q Tinnitus q Tonsillitis q Ulcers q Urinary tract infections q Vision changes q Visual/eye problems q Worry q Other:

______________________________________________________

(D) Physical Health • Did you suffer any significant injuries, falls or traumas during adulthood?

q Yes q No (If yes please explain) ____________________________________________________________________________________________

• Have you had any hospital visits/surgeries? q Yes q No (If yes please explain/dates) ______________________________________________________________________________________

• Have you had any broken bones or dislocations? q Yes q No (If yes please explain/dates) ______________________________________________________________________________________

• Have you ever had any head injuries/been knocked unconscious? q Yes q No (If yes please explain/dates) ______________________________________________________________________________________

(E) Chemical Health

• Are you currently taking any prescription or other medications (including antibiotics)? q Yes q No

(If yes, what are you taking, how long have you been taking it and why?) __________________________________________________________________________________________________________________

• Are you currently taking any supplements? q Yes q No (If yes, what are you taking, how long have you been taking it and why?) __________________________________________________________________________________________________________________

• Do you, or did you smoke? q Quit q Yes q No (If yes how much & for how long have you smoked?) ____________________________________________________________

• Do you drink alcohol? q Yes q No (If yes how much) ________________________________________________________________________________________________

• How much water do you drink on a normal day? _________________________________________




(F) Mental/Emotional Health

Please indicate how you are coping with life’s stresses. 10/10 indicates an area where you are under extreme stress. (Please rank from 1 to 10 with 1 being minimal to 10 being extreme)

Current Level of Stress Can this improve? What level would you like in 3 months?

Work & Career q Yes q No

Relationships q Yes q No

Financial Stress q Yes q No

Family Stress q Yes q No

Busyness q Yes q No

Health & well-being q Yes q No

(G) Health Measures

Please indicate on the following scales, your level of health in each area. 10/10 is very good. (Please rank from 1 to 10 with 1 being minimal to 10 being best)

Current Level of Health Can this improve? What level would you

like in 3 months?

Ease of falling asleep q Yes q No

Quality of sleep q Yes q No

Ease of waking q Yes q No

Energy levels q Yes q No

Mental clarity/sharpness q Yes q No

Concentration/focus levels q Yes q No

Your immune system q Yes q No

Other: q Yes q No

Overall health q Yes q No

Thank you for completing this form.

Signed __________________________________________________ Dated _______________________

Print name __________________________________________________




Practitioner Notes:

vitae health history form adult

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