Health History Questionnaire - On Demand Counseling Services

Client Name (First, MI, Last) *

Has the client has any of the following health problems? *

AnemiaArthritisAsthmaBleeding DisorderBlood Pressure (high or low)Bone/ Joint ProblemsCancerCirrhosis/ Liver DiseaseDiabetesEpilepsy/ SeizuresEye Disease/ BlindnessFibromyaligia/ Muscle PainGlaucomaHeadachesHead Injury/ Brain TumorHearing Problems/ DeafnessHeart DiseaseHepatitis/ JaundiceKidney DiseaseLung DiseaseMenstrual PainOral Health/ DentalStomach/ Bowel ProblemsStrokeThyroidTuberculosisAIDS/HIVSexual Transmitted DiseaseLearning ProblemsSpeech ProblemsAnxietyBipolar DisorderDepressionEating DisorderHyperactivity/ ADDSchizophreniaSexual ProblemsSleep DisorderSuicide Attempts/ ThoughtsOther

Please note family history of any of the above conditions and client's relationship to that family member.

If you have had medical hospitalizations/ surgical procedures in the last 3 years please explain:

Allergies/ Drug Sensitivities *

NoneFood (specify)Medicine (specify)Other (specify)

Please indicate any food allergies

Please indicate any drug sensitivities.

Please indicate any food allergies/drug sensitivities.

When was your last physical examination? By whom?

Have you had any of the following symptoms in the past 60 days? Please check all that apply.

Use of complimentary health approaches (Dietary supplements, mind and body practices, massage/yoga, meditation, etc.)

Current Prescribed Medication List (Please include: Medication Name, Dose, Prescribing Physician and Diagnosis)

I have read the Description of Telehealth services

I consent to the services agreement