HEALTH HISTORY QUESTIONNAIRE

Congratulations! You have just taken the first step toward wellness. The human body is designed to be healthy. Throughout life though, events occur which damage your health. This case history will uncover the layers of damage that have resulted in poor health. Following your exam, Kathrine will outline your program to begin to correct these layers of damage and recover your innate health potential.

* Required

















Male
Female

Married
Single
Divorced
Widowed













Work
Sleep
Routine
Other




Yes
No


Extremely Important
Very Important
Reasonably Important
Minimally Important



Work
Sports
Auto
Trauma
Chronic
Other




Yes
No

Yes
No


Severe
Moderate
Mild

Yes
No



Yes
No



Severe
Moderate
Mild

Yes
No



Yes
No


Sit
Stand
Computers
Drive
Desk
Physical Work
Heavy Lifting

Yes
No




Yes
No


Yes
No


Yes
No


Yes
No



Yes
No






Yes
No

Mild
Moderate
Extreme

Yes
No

Mild
Moderate
Extreme

Yes
No

Mild
Moderate
Extreme

Yes
No

Mild
Moderate
Extreme

Yes
No

Mild
Moderate
Extreme

Yes
No

Mild
Moderate
Extreme

Yes
No


Mild
Moderate
Extreme

Excellent
Good
Fair
Poor
Improving
Same
Getting worse

Excellent
Good
Fair
Poor
Improving
Same
Getting worse




Dizziness/Fainting
Neck stiffness
Enlarged lymph glands
Headaches
Ear Problems
Eye Problems
Sinus infection
Allergies/Sinus problems
Sore throat
Other

Hives
Rashes/Excema
Changes in moles or lumps

Chronic cough
Coughing up phlegm
Wheezing/asthma
Frequent colds
Other

Palpitations
Chest pain or tightness
Poor circulation
Swelling of ankles

Indigestion
Bloating
Diarrhoea/Constipation
Poor appetite/ hunger
Nausea
Haemorrhoids
Food cravings
Other

Joint disorder
Sore or painful muscles
Difficulty walking
Spinal curvature
Backache or pain
Numbness/tingling of limbs
Other

Genital discharge/pain
Painful/frequent urination
Excessive/scanty urination
Blood in urine
Diminished bladder control
Other

Frequent UTI’s
Frequent vaginal infection
Pelvic inflammatory disease
Abnormal pap smear
Irregular periods
Painful menstrual periods
Menopausal symptoms
Premenstrual symptoms
Other

Lumps in testicles
Prostate problem
Weak urinary stream
Impotence
Other

Insomnia
Vivid dreams/nightmares
Anxiety
Irritability
Forgetfulness
Depression
Fatigue
Thirst
Psychiatric treatment
Other






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