Health History Questionnaire |
Welcome to our clinic! Please fill out this form as completely as you can. The more information you can give us, the better we are able to assist you. The information you provide for us is absolutely confidential. If you have any questions or concerns, please do not hesitate to contact one of our staff members.
*Indicates required fields |
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Date
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First Name*
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Last Name*
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Address
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Gender*
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City*
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Province*
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Home Phone # *
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Postal Code
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Work Phone #
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Cell Phone #
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 May we leave messages at any of these numbers? (The information may be an appointment reminder, or more sensitive, personal health information) |
May we leave a Message:
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Details:
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If patient is a child: |
Father's name:
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Mothers name:
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Spouse's name:
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Children (name & age):
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Names Of Other Health Care Providers: |
Primary Care/Medical Doctors:
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Specialists:
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Chiropractor:
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Others:
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Who referred you to our clinic?
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Your Main Health Concerns: |
What are your main health concerns?
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When did these concerns begin, (be specific)?
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Your Past Medical History: (please check and date) |
Cancer
date:
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High Blood Pressure
date:
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Heart Disease
date:
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Diabetes
date:
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Rheumatic Fever
date:
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Seizures
date:
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Hepatitis
date:
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Thyroid Disease
date:
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Venereal Disease
date:
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| (if applicable please check, date, & describe the following) |
Other Major Illness
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Significant Trauma (auto accidents, falls,other)
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Allergies (drugs, chemicals, foods)
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Occupational Stress: |
Please describe in detail if applicable:
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Describe Weekly Exercise: |
Please desribe in detail:
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Current Medicines: |
Please list all prescriptions, supplements and over-the-counter preparations taken regularly:
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Diet and Habits: |
| How many meals do you have per day, on average? |
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| Are you currently on, or have you ever been on a restricted diet? |
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| If you are a smoker, how many packs per day/week? |
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How much coffee, tea, cola, or alcohol do you consume daily?
(please list out for each) |
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Coffee/Tea |
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Cola |
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Alcohol |
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| Do you partake of any recreational drugs or activities? |
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Indicate Painful or Distressed Areas: |
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Below are groups of symptoms. Please check any that you may have experienced in the last 6 months. |
Generals: |
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Poor Appetite |
Poor Sleep |
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Fatigue |
Cravings |
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Strong Thirst |
Night Sweats |
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Sweat Easily |
Change in Appetite |
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Bleed/Bruise Easily |
Peculiar Taste/Smells |
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Weight Gain |
Weight Loss |
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Chills |
Fevers |
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Sudden Energy Drop |
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(time of enery drop)
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Skin and Hair: |
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Rashes |
Itching |
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Eczema |
Change in Skin/Hair Texture |
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Loss of Hair |
Dandruff |
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Recent Moles |
Ulcerations |
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Pimples |
Non-healing Wounds |
Other skin or hair symptoms?
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Head, Eyes, Nose and Throat: |
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Headaches |
Neck Pain |
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Concussion |
Eye Pain |
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Eye Strain |
Blury Vision |
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Using Glasses |
Night Blindness |
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Colour Blindness |
Cataracts |
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Earaches |
Poor Hearing |
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Ring in Ears |
Facial Pain |
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Sinus Problems |
Nose Bleeds
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Jaw Pain |
Tooth Pain |
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Mercury Fillings |
Sore Throat |
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Sore on Lips/Tongue |
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Cardiovascular: |
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High Blood Pressure |
Low Blood Pressure |
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Irregular Hearbeat |
Dizziness |
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Fainting |
Chest Pain |
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Varicose Viens |
Blood Clots |
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Cold Hands/Feet |
Swelling of Hands |
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Swelling of Feet |
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Respiratory: |
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Difficulty Breathing |
Cough |
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Bronchitis |
Asthma |
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Pain With Deep Breath |
Production of Phlegm (colour) |
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Coughing Blood |
Pneumonia |
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Other |
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Gastrointestinal: |
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Indigestion |
Gas |
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Bad Breath |
Constipation |
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Abd. Pain/Cramps |
Nausea |
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Vomitting |
Laxative Use |
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Rectal Pain |
Hemorroids |
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Blood in Stool |
Diarrhea |
Urinary: |
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Urgency to Urinate |
Pain to Urinate |
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Wake to Urinate |
Decrease in Flow |
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Odd Colour/Smell |
Blood in Urine |
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Impotency |
Sores on Genitals |
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Other |
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Gynecological: |
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Irregular Period |
Painful Period |
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Breast Tenderness |
Vaginal Discharge |
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Vaginal Sores |
Heavy Flow |
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Light Flow |
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| Age of first menses |
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| Duration of menses |
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| Days between menses |
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| Date of start of last mensus |
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| Date of last PAP? |
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| Changes in body or emotions prior to menstruation |
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| Do you practice birth control? |
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| What type of birth control and for how long? |
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| Are you Satisfied with this method? |
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| Number of Pregnancies |
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| Number of Births |
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| Number of Miscarriages |
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| Number of Abortions |
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Neuro-Psychological: |
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Loss of Balance |
Poor Memory |
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Depression |
Lack of Co-ordination |
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Areas of Numbness |
Anxiety
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| Have you been treated for Psychological issues before? |
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| Have you ever considered suicide? |
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Any and all information collected by Dr. Janice Dacyshyn is strictly confidential and accessible only to Dr. Janice Dacyshyn. Dr. Janice Dacyshyn collects the above information solely for the purpose of of bulding a medical history for individuals who use her services.
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