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Met427 haq health history

Name __________________________________________________________________________________ Date of Birth _______________ Today’s Date ______________ Occupation ______________________________________________________________________ Age ______ Height ______ Sex ______ Number of Children ______ Are you recovering from a cold or flu? ____________ Are you pregnant? ____________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Date of last physical exam ___________ Practitioner name and phone number___________________________________________________________________________ Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis): _______________________________________________________________________________________________________________________________________________ Outcome ______________________________________________________________________________________________________________________________________ What types of therapy have you tried for this problem(s): ❑ other __________________________________________________________________________________________________________________________________ List current health problems for which you are being treated: __________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________ Current medications (prescription or over-the-counter): ________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________ Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications (if any) and dates: _____________________________________________________________________________ _________________________________________________ _____________________________________________________________________________ _________________________________________________ Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems): ______________________________________________________ Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months? ____________________ Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, farmer, miner)? _______________________________________________________________________________________________________________________________________________ ❑ Medical devices/prosthetics/implants, describe: ________________________________ ❑ move around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers) Strong like for any of the following flavors: Strong dislike for any one of the following flavors: ❑ sour Do you: ❑ Prefer warmth (i.e., food, drinks, weather, etc.) ❑ Prefer cold (i.e., food, drinks, weather, etc.) ❑ No preference Is your sleep disturbed at the same time each night? _______ If yes, what time? _______ Time of day you feel the most energy or the least symptoms: Time of day you feel the worst or your symptoms are aggravated: ❑ 9 a.m. - 11 a.m. ❑ 11 a.m. - 1 p.m.
❑ 9 a.m. - 11 a.m. ❑ 11 a.m. - 1 p.m.
❑ 9 p.m. - 11 p.m. ❑ 11 p.m. - 1 a.m.
❑ 9 p.m. - 11 p.m. ❑ 11 p.m. - 1 a.m.
Do you experience any of these general symptoms EVERY DAY?
Medical History
Health Habits
Current Supplements
Medical (Women)
Would you like to:
Nutrition & Diet
Family Health History
(Parents and Siblings)
Food Frequency
Fruits (citrus, melons, etc.) ___________ Eating Habits
Medical (Men)
2000 Lyra Heller, Michael Katke. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law.
MET427 7/00 Rev 1/03



LAS ENSEÑANZAS DE KRYON El Grupo de Kryon Kryon canalizado por Mario Liani El Grupo de Kryon es la denominación que Mario Liani emplea para canalizar la amorosa energía de Kryon, la cual no representa a una entidad aislada, sino a un grupo de conciencias superiores de ascendencia angelical que opera sin individualidades y bajo una absoluta sincronía. Kryon está siendo canaliz

I and rm questionnaire

PATIENT INFORMATION/QUESTIONNAIRE Please complete and return this form to: Cohen Center Also, please arrange to have a copy of your previous medical records and the films of your Hysterosalpingogram (HSG), if applicable, sent to Cohen Center. No appointment will be made unless the records and films are available for the physician. You may call approximately one week after having thi

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