Patient Health History Form

Hidalgo Integrative Medicine, PLLC

Patient Health History

Please fill out this health history before coming to your appointment:

Habits

Social History

Family History: Please specify WHICH family member and AGE of diagnosis

Have you ever had or currently have any of the following medical conditions

Neurological

Alzheimer’s dementiaSeizures or epilepsyMigraine headachesTension headachesStrokeMultiple Sclerosis

Skin

AcneCold soresEczemaPsoriasisRosaceaSkin cancer or pre-cancer

Mental Health

AnxietyDepressionAddiction to drugsAlcoholismInsomnia

Eye, Ear, Nose, Throat

Visual impairmentCataractsGlaucomaHearing lossSinusitis, frequentEar infections, frequent

Kidney

Kidney failureKidney stones

Lung and Respiratory

AsthmaSleep apneaEmphysema (COPD)Tuberculosis or positive PPD

Allergy, Immune

Seasonal or environmental allergiesOther Allergies (specify below)AnaphylaxisUrticaria (hives), frequent

Heart and Vascular

Hypertension (high blood pressure)High cholesterolAngina (cardiac chest pain)Coronary disease or heart attackAtrial fibrillationCongestive heart failure

Hormonal

DiabetesOsteoporosis or OsteopeniaThyroid disorderVitamin D deficiency

Gastrointestinal

Diverticulosis or diverticulitisColon polypsHemorrhoidsHepatitis (specify type below)Irritable Bowel SyndromeReflux disease (GERD)Ulcers, stomach or duodenal

Genitourinary, STD, Reproductive

Genital herpesGenital wartsHIV/AIDSPrior Chlamydia or GonorrheaSyphillisInfertilityErectile dysfunctionProstate enlargement (BPH)EndometriosisMenopause (age below)Urinary tract infections, frequentUrinary incontinenceVaginal yeast or infections, frequent

Musculoskeletal

Back painGoutNeck painOsteoarthritis (specify locations below)Rheumatoid arthritis

Cancers and Blood

Anemia (low blood count)Blood clots (specify location below)Cancer (specify type below)