BACK TO BASICS HEALTH & NUTRITIONCOMPREHENSIVE HEALTH HISTORY
Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural healthcare. The ability to draw effective conclusions about your state of health and how to optimize its
improvement may be influenced by many factors. The information from this form will assist toprovide you with an optimal plan of health care.
Date _____________________________First Name ________________________ Middle ________________ Last_______________________________
Address ________________________________ City _____________________ State _____ Zip Code________
Home Phone (_____) ______-__________ Work (_____) ______-__________ Cell (_____) ______-__________
Email _____________________________________
Gender:Age ______

Date of Birth _____/_____/__________o Female o Male								Marital Status:o Single o Married o Divorced o Widowed o Long Term Partnership

Genetic Background – please check appropriate box(es):o Caucasian o Native American o African American o Hispanic o Mediterranean o Asiano Other ___________________________________________________________________________________
Occupation ______________________________________________________ Hours per week ____________Nature of Business _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Emergency Contact: _________________________________________ Phone ___________________________
Name, address, & phone number of primary care physician:________________________________________________________________________________________________________________________________________________________________________________________________________________________________BACK TO BASICS HEALTH & NUTR ITION    Page 1SYMPTOMS AND AREAS OF CONCERN Please check all that apply.

o Acneo ADD/ADHDo Adrenal Glands
o Allergies
o Alzheimer’s Diseaseo Anemiao Angero Anxietyo Appetite
o Arteriosclerosiso Arthritis
o Asthmao Back Paino Bad Breatho Bed Wettingo Bell’s Palsyo Biteso Bladdero Blood Pressure - Higho Blood Pressure - Lowo Boilso Boneso Breathingo Bronchitiso Bruiseso Burnso Cancero Candidao Canker Soreso Carpal Tunnelo Cataracts
o Chest Congestiono Chest Paino Cholesterolo Circulationo Cold - Commono Cold - Temperatureo Colic
o Colono Constipationo Cougho Cravingso Dandruff
o Depressiono Diabeteso Diarrhea
o Digestiono Dizzy Spells
o Ear Infectiono Ear Ringing
o Edemao Emphysemao Epilepsyo Eyesighto Fatigue
o Fevero Fluo Gallstones
o Gangrene
o Gas
o Gouto Gumso Hair Issues
o Headacheo Heart Issues
o Heartburno Hemorrhoidso Herpeso Hiatal Herniao Hiveso Hormoneso Hyperactiveo Hypertensiono Hyperthyroidismo Hypoglycemia
o Impotenceo Incontinenceo Indigestiono Insomnia
o Joint Paino Kidney Issues
o Kidney Stoneso Laryngitiso Leprosyo Leukemia
o Livero Lung Issueso Lupuso Lymph Glands
o Menopauseo Menstrual Crampso Migraineso Mononucleosis
o Mucouso Nailso Nauseao Nervousnesso Nose Bleedso Parasiteso Parkinson's Diseaseo Perspirationo PMSo Pneumonia
o Polyps
o Pregnancy
o Prostateo Psoriasis
o Rasho Reproductiveo Respiratory
o Rheumatismo Ring Wormo Seizureso Shingles
o Sinuso Skin Issueso Snoringo Sore Throato Stomacho Stresso Strokeo Styo Teethingo Tennis Elbow
o Tonsillitiso Tumorso Ulcerso Urinary Infections
o Varicose Veinso Vertigoo Weight
o Yeast Infections

Other Symptoms/Concerns _______________________________________________________________________________________________________________________________________________________________BACK TO BASICS HEALTH & NUTR ITION    Page 2

SYMPTOMS AND AREAS OF CONCERN (continued)		

What medical diagnosis or explanation(s), if any, have been given to you for these symptoms/concerns?
______________________________________________________________________________________________________________________________________________________________________________________
What physician or health care providers (alternative practitioners) have you seen for these conditions?
______________________________________________________________________________________________________________________________________________________________________________________MEDICATIONS
List all medications – include all over the counter non-prescription drugs.
Medication Name

Date Started

Date Stopped

DosageList all vitamins, minerals, and any nutritional supplements that you are taking now.
TypeDate Started

Date StoppedDosage

Are you allergic to any medication, vitamin, mineral, or other nutritional supplement?  

o Yes o No

If yes, please list: ________________________________________________________________________________________________________________________________________________________________________BACK TO BASICS HEALTH & NUTR ITION    Page 3

NUTRITIONAL
Do you currently follow a special diet or nutritional program?  

o Yes o No

Are you any of the following:o Paleo o Diabetic o Dairy Restricted o Vegetarian o Vegan o Blood Type Diet o Ketoo Other (describe) __________________________________________________________________________Is there is anything special about your diet:___________________________________________________________________________________________
Do you have symptoms immediately after eating, such as belching, bloating, hives, etc?  

o Yes o No

If yes, are these symptoms with a particular food or supplement? _____________________________________
Does skipping meals greatly affect you?  

o Yes o No

Do you have an aversion to certain foods?  

o Yes o No

If yes, what food(s) ___________________________________________________________________________
What foods do you crave?______________________________________________________________________How much of the following do you consume? (1D=once daily, 2W=twice a week, 3M=three times a month)
Soda Pop ____________

Coffee ____________

Smoking _____________

Alcoholic Bev ____________

Fast Food ____________

Milk ______________White Flour ___________

Sugar Usage _____________

Raw Fruit ____________

Meat _____________

Raw Veggies __________

Whole Grains ____________LIFESTYLE
Do you smoke?

o Yes o No

If yes, how much? ___________________________________________________________________________		
Are you exposed to 2nd hand smoke regularly?

o Yes o No

If yes, please explain:___________________________________________________________________________________________________________________________________________________________________
Average number of hours that you sleep at night?

o less than 6 o 6-8 o 8-10 o more than 10

BACK TO BASICS HEALTH & NUTR ITION    Page 4

LIFESTYLE (continued)
Do you exercise regularly?

o Yes o No
Times/Week

If yes, please indicate:Type of exercise

1x

2x

3x

Length of Session
4x/+ ≤15 min

16-30
min

31-45
min

>45minJogging/Walking
Aerobics
Strength Training
Pilates/Yoga/Tai Chi
Sports (tennis, golf, water sports, etc)
Other (please list below)____________________________
If no, please indicate what problems limit your activity (e.g., lack of motivation, fatigue after exercising, etc.)__________________________________________________________________________________________
What are your top 3 health concerns?

Who referred you for your appointment today? ____________________________________________I understand that I am here to learn about nutrition and better health practices and that I will beoffered information about food supplements and herbs as a guide to general good health and this isa personal ministry and spiritual counseling.
I fully understand that those who counsel me are not medical doctors and I am not here for medical
diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent
for federal, state, or local agencies or on a mission of entrapment or investigation.
The services performed here are at all times restricted to consultation on nutritional mattersintended for the maintenance of the best possible state of natural health and do not involve thediagnosing, treatment, or prescribing of remedies for disease.
Signature______________________________________________ Date________________________BACK TO BASICS HEALTH & NUTR ITION    Page 5