Health Assessment Form

Michael Taylor
First Name Last Name

Single Married Divorced Separated Widowed

Marital Status

6262 Swan Park
Address

Waimanalo HI 96795
City State Zip

5384609926 April 1, 1951
Phone DOB

Spouse Name Spouse Phone

Is the requested medication NEW or a CONTINUATION of THERAPY? If so, start date: __________

Have you been hospitalized in the past year? Yes No

Review of Symptoms

Allergies	Black Outs
Blurred Vision	Calf Pain
Chest Pain	Chills
Coughing	Coughing Up Blood
Dental Problems	Difficulty Emptying Bowel Or Bladder
Double Vision	Enlarged Glands
Excessive Bruising	Excessive Stress
Excessive Thirst	Eye Pain
Fatigue	Fever
Headaches	Hearing Loss
Irregular Heart Rate	Joint Swelling
Muscle Pain	Seizures
Shortness Of Breath	Stomach Trouble Or Ulcers
Tuberculosis Exposure	Weight Gain Or Loss Greater Than 10 Lbs

Previous Health History

Dr. Sarah Johnson 06-18-1957
Primary Care Physician Last Seen Date

Have you received chiropractic care? Yes No

Have you received acupuncture care? Yes No

PRESCRIPTION DRUGS:

Antidepressants	Anti Inflammatory
Birth Control Pills	Blood Pressure Medication
Diet Pills	Blood Sugar Medication
Muscle Relaxers	Insulin
Pain Pills	Sleeping Pills

Other:

Over-the-Counter Drugs

Accidents or Injuries

hyaluronic acid, resveratrol, carnitine, inositol

Vitamins or Supplements