Natural Health Clicic of Des moines

Patient Assesment Questionnaire

In order to insure you get the best results from the supplements that available from Drlynnmykel.com, I need to know a little more about your current state of health and medications you may currently be taking. All information is confidential.

Please fill out form, print and bring with you to your appointment.



General:



Women Only:









Gastrointestinal:



Eye, Ear, Nose, Throat:

Cardiovascular:



Men Only:


Skin:

Muscle/Joint/Bone:

Genito-Urninary:

Conditions:

Check Conditions you have or have had in the past...










FAMILY HISTORY Fill in the information regarding your family









Hospitalizations:







Serious Illness or Injury







Check if your blood relatives had any of the following diseases

Arthritis

Gout

Athsma

Hay Fever

Cancer

Chemical Dependancy

Diabetes

Heart Disease

Strokes

High Blood Pressure

Kidney Disease


Lifestyle Environment

Health Habits:


Occupational Concerns:



Diet:


Lifestyle Environment







Home

New Houseold Items

Yes No
Yes No


I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of her staff responsible for errors or omission that I may have made in the completion of this form. (sign and date)

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