Health History Form #2 Fields marked with an * are required Health History Health Habits Family History Sign and Submit First Name * Last Name * MI Email * Marital Status Single Married Partnered Separated Divorced Widowed How did you hear about us Internet Search Insurance Directory Referred by patient Other Other Date of last Physical Exam Date of last Pap Smear Date of last Menstrual Cycle Patient Condition Patient Condition Is the condition worse? Yes No How often do you have this pain/condition Does it interfere with you work, sleep and daily routine Yes No Rate your pain on a scale from 1 (least pain) to 10 (severe pain)? Activities that are painful to perform Sitting Standing Walking Bending Lifting What treatment have you already received for your condition? Medication Surgery Physical Therapy Please list all medications Please list all of the medications that you are taking, include over the counter medications and herbs. Medication Dose Last Taken Add another? Allergies to Medications: Yes No Health Habits and Personal Safety Health Habits and Personal Safety Exercise Sedentary (No Exercise) Mild Exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional Vigorous Exercise (i.e. work or recreation less than 4x/week for 30 min.) Regular Vigorous Exercise (i.e., work or recreation 4x/week for 30 minutes) Divider Diet Diet Are you dieting Yes No # of meals you eat in an average day Rank Salt Intake Hi Med Low Rank Fat Intake Hi Med Low Caffeine None Coffee Tea Cola # Cups / Cans Per Day If you are a human seeing this field, please leave it empty.