Short Form Health Assessment

First Name: Last Name: Today's Date: Male

Height: ft. in. Weight: lbs. Date of Birth: Age: Female

Bowel Movements per day: 0 1 2 3 4+ Blood Pressure: Right: Left:

Do you, or have you ever had difficulty with any of the following? Please check those that apply.
Cold Hands or Feet / Difficulty Warming

Liver/ Gallbladder /
Current Past Hepatitis A, B, or C Current Past
List:
Irregular Heart Beat / Arrythmia's
(Glandular System)

Current Past Anemia Current Past

Blood
(Also Adrenals/Cardiovascular)
Jaundice: Skin / Eyes
Thyroid

Overweight Current Past Current Past

Low Energy / Always Tired Current Past Light Colored or White Stools Current Past
Goiter / Hashimoto's / Grave's Current

Cardiovascular
Past Myocardial Infarction (Heart Attack) Current Past

Hypo or Hyper-Thyroid Current Past Pacemaker / Stents Current Past

Mental Health Challenges Current Past
Angina / Chest Pain / Chest Pressure Current Past
(Depression, OCD, Anxiety etc.)
Hemorrhoids / Prolapse of Any Tissue Current Past Dermatitis / Eczema / Psoriasis Current Past
Dry, Itchy Skin or Overly Oily Skin
Parathyroid

Osteoporosis /Osteopenia/ Scoliosis Current Past Current Past

Spinal Deterioration / Herniated Blemishes / Rashes / Acne
Skin

Current Past Current Past

Discs / Bone Spurs (Also Kidneys/Lymphatic)
Is Your Bladder: Strong A Few Leaks Weak
Dandruff Current Past
Hernia? Where? How Much Do You Sweat? Low Medium Excessive
Current Past
(Also Thyroid)
Acid Reflux / Heartburn / Indigestion Current Past Cold & Flu-like Symptoms Current Past
Pancreas

Undigested Food in Stool Current Past Swollen Lymph Nodes Current Past
Slow Digestion Current Past 'Cancer' Anywhere in the Body Current Past
MS / ALS / Parkinson's / Palsy
Lymphatic System

Current Past Non-Malignant Masses Anywhere in the Body Current Past

Any "Itis" Condition? (Arthritis, Bursitis, etc.)

(Glandular System)

Current Past Gout / Toxemia / Cellulitis Current Past

Please list:
Adrenals

High Blood Pressure/ Low Blood Pressure

Current Past Poor Memory / Brain Fog Current Past
(Also Kidneys)
Diabetes : TYPE I / TYPE II (Also
Current Past Hair Loss Current Past
Pancreas)
Sleep Challenges (getting to/staying asleep) Current Past Edema (Fluid Retention) Current Past
(Also Pineal/Pituitary)
ADD / ADHD / Autism Current Past AIDS / HIV + Current Past
Irregular Menses (Also Pituitary) Current Past Weak Bladder / Incontinence Current Past
(Also Parathyroid)
Ovarian Cysts / Fibroids / Fibrocystic
Reproductive

Kidneys & Bladder

Current Past Kidney Stones Current Past

Breasts
Difficulty Conceiving Current Past Nephritis / Kidney Failure Current Past
Low / Excessive Sex Drive Current Past UTI / Bladder Infection / Cystitis Current Past
Prostate Problems Current Past Lower Back Weakness / Lack of Strength Current Past
Crohn's / Colitis / Gastritis /
Current Past Sciatica Current Past
Gastro-Intestinal

Enteritis /Diverticulitis
Diarrhea / Constipation / Gas Current Past
Bronchitis / Asthma / COPD / Current Past
Respiratory
Tract

Emphysema
System

Stomach / Intestinal Ulcers Current Past Collapsed Lung: Right or Left Current Past
Coated Tongue (white, yellow, green, brown) Current Past Painful Breathing / Difficulty Breathing / SOB Current Past
List: (Also Adrenals)
What is your biggest health concern?

Are you taking any herbal formulas or medications? Please list:

Updated Jan. 2021