Health Questionnaire

Name________________________________ Contact#_______________________

Address_______________________________ Today’s Date___________________

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What is your Current Medical History?

 

 

What Symptoms do you currently have?

 

 

 

What areas of health would you like to have addressed or have help with?

 

Current Medications_______________________________________________________________________________________________________________________________________

Comments______________________________________________________________________________________________________________________________________

-----------------------------------To be completed by Consultant------------------------------------

Assessment

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Recommendations

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PRIVACY STATEMENT: The privacy of your health information is protected. This organization will protect the privacy of your health information as required by law. Your private health information will not be disclosed to anyone other than you without your consent.