NAME

Birth Date

Age

Weight

Height

Gender

Address

TEL

FAX

Email

Describe Current Condition

MEDICAL OPINION (if any

YOUR OPINION (intuition)

DESCRIBE HOW PROBLEM STARTED

Include environmental issues before or during

HEALTH HISTORY

Childhood Diseases (circle one) Mumps, Measles, Rubella, Chicken Pox, Pneumonia,
Whooping Cough, Scarlet Fever, Other

VACCINATIONS (Circle) MMR, DPT, POLIO, CHICKEN POX, TB, Other

DISEASES

OPERATIONS

Major health problems of Blood Mother & Father

Major health problems of Blood Grandparents

Health problems of Siblings, Aunts and Uncles

ADDITIONAL COMMENTS

Picture