Personal Health History

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Place of birth:_

Current Conditions


Medical History

Year Diagnosed

Previous Operations



Previous Injuries/Medical Conditions Year

Mental Illnesses

Year Diagnosed

Current Prescription Medications Medication


Length of Time You Have Taken the Medication

Current Nonprescription Medications ^^^^ Medication Dose

Length of Time You Have Taken the Medication

Drug Allergies

Medication Reaction

Social History

Marital status: Married or single No. of children:

Sexual history:

No. of sexual partners in your lifetime:_

Sex of sexual partners: Male, female, or both Practice safer sex? Yes or No

Preventive Health History

Tobacco: Have you ever used tobacco products? Yes or No

No. of cigarettes smoked per day:_

No. of cigars smoked per day: _

Amount of chewing tobacco or snuff used per day: _

No. of years you used chewing tobacco or snuff: _

Have you ever quit? Yes or No

Alcohol: No. of drinks per week: _

Have you ever quit? Yes or No Have you abused alcohol? Yes or No

Illicit drugs: Have you ever used illicit drugs? Yes or No

Which drug(s) have you used?_

When was your last use?_

Exercise: Do you regularly exercise? Yes or No

If yes, what type of exercise?_

How often do you exercise per week?_

Length of exercise sessions: _

Seat belt use: Yes or No

Glasses of water per day: _

No. of servings of fruits per day: _

No. of servings of vegetables per day: _

No. of servings of meat per day: _

No. of servings of dairy products per day: _

No. of servings of whole-grain products per day:

Smoke alarm in home? Yes or No

Carbon monoxide Yes or No detector in home?

Gun: Do you keep a gun in the home? Yes or No

If yes, is it locked? Yes or No If yes, is it loaded? Yes or No


Year of Last

Vaccination Vaccination

Tetanus/diphtheria _

Pneumococcal vaccine _

Flu vaccine _

Measles, mumps, rubella _

Polio _

Varicella (chickenpox) _

Hepatitis A _

Hepatitis B _

Family Health History

Living Age at Medical Conditions and/or

Relative (yes/no) Death Cause of Death


Grandparents Paternal grandfather Paternal grandmother Maternal grandfather Maternal grandmother Uncles and aunts

Primary doctor


Current Doctor(s)—

Medical Specialty Address Phone No.

Medical Specialty Address Phone No.

Health Insurance

Health insurance company _

Your identification no._

Phone no. of insurance company_

86 vaccinations you have received and the dates when you last had them. Include

Staying information about sexually transmitted diseases such as genital warts.

Healthy Include information about your family health history to see if you may have inherited a predisposition to a certain disorder such as heart disease, diabetes, or cancer. Write down the name and the phone number of your health insurance company or health maintenance organization. Finally, list the names, addresses, and phone numbers of all of the doctors you now see.

Take your written personal health history with you each time you have an appointment with a new doctor or other healthcare professional. The information will help them more easily become familiar with you and your health problems.

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Herbal Healing For Everyone

Herbal Healing For Everyone

Disease isn't complicated it's really very easy and the application of good sense techniques may defeat any disease. All microbes and viruses are weak and may be defeated easily with cleaning and nutrition.

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