Health History Form

Call Us 217-528-3199

Dr. Na Zhai Clinic

1200 S. 5th Street

Springfield, IL 62703

Tel. 217-528-3199

Your privacy is important to us. The following form is intended to reduce the amount of paperwork needed to be done on your first visit in our office and give us more detailed information about you. If you prefer to fill this form out at the clinic, please feel free to do so. Please contact us if you have any questions.

1. About you

Name:

	Mo/Dy/Year
Birthday:

Marital Status:

Address:

Address line2:

City:

State:

Zip:

E-mail address:

Home Phone:

Cell:

Employer:

Work Phone:

2. In case of Emergency

Name:

Phone:

Relationship:

3. Your Physician

Name:

Phone#


Is your physician aware of your visit in this office ?	Yes No

4. Health Insurance

Phone:

Name of insured:

ID #

Group#

5. Present Illness

Please briefly tell us what symptoms you are concerned with. Please list the most severe ones first.

First:

Severity:

	How long have you been suffering from it?

Second:

Severity:

	How long have you been suffering from it?

Third:

Severity:

	How long have you been suffering from it?

Do you have any more medical issues that you would like to tell the doctor?

Are you currently taking any medications? If so, for what symptoms?

6. Medical History

Height

Weight

Do you generally feel weakness, fatigue or fever?

Frequent cold?

	Yes
	No

Do you have or have you ever had headaches or dizziness?

	Yes
	No

If yes, please explain


Any problems with your blood pressure?


Any problems with your heart?

How about your lungs and breathing?

How is your digestion?

How many times bowel movements do you have each day? Odorous? Diarrhea? Constipated?

Do you have any skin problems?


Do you smoke?	Yes No


If yes, how many cigarettes per day or have you tried to quit

Do you have or have you ever had a problem with alcohol?	Yes No

Do you have or have you ever had a problem with drugs?	Yes No

Have you ever been diagnosed with a mental illness?	Yes No

If yes, when and what was the diagnosis?

Have you ever been hospitalized?	Yes No

If yes, please provide the date and specific problem


Have you ever had surgeries?	Yes No

If yes, please provide the date and specific problem

Other major illnesses, major injuries, cancer, chemotherapy, radiation


Do you have any sensitivities or allergies to food or medication?	Yes No

If yes, please list


Have you ever been diagnosed with a dental disease ?	Yes No

If yes, when and what type

Check the Box that Most Accurately Describes Your Current Lifestyle

	Sedentary lifestyle with little exercise
	Occasional Vigorous exercise in work or leisure
	Mild exercise in job,house or recreation (such as climbing stairs, walking over 3 blocks, golfing, bowling, etc.
	Regular vigorous exercise

Check the Box that Describes Your Current Ambulatory Condition

	Ambulatory
	Semi-Ambulatory
	Wheel Chair Needed

Check Any Medications You Have Used Before

Other Medications:

7. Menstrual History

Do you have regular menstruation?

	Yes
	No

If no, please explain

Cramping during menstruation?

	Yes
	No

How many days of heavy bleeding during your menstruation?

Date of your last menstruation

Number of pregnancies

Number of miscarriages

Hormonal Replacement Therapy

Birth Control Method

8. Family History


How old is your father?

How old is your mother?

Please check the following conditions if any applies to them:

9. How did you hear about Dr. Na Zhai

Name:

Phone Number:

Or Referred by:

What motivated you to come to Dr. Na Clinic?

Please wait...

Dr. Na Zhai Clinic offers Alternative Medincine featuring Holistic Natural cures.
Powered by www.websiteforge.com