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Alpine
Eastern Medicine
Health History Form
Private & Confidential
Patient Information
Full Name
Date of Birth
Phone Number
Email Address
Mailing Address
Occupation
Emergency Contact (Name & Phone)
Reason for Visit
What is the primary reason for your visit today?
How long has this been occurring?
On a scale of 1-10, how severe is it?
Select...
1 - Mild
2
3
4
5 - Moderate
6
7
8
9
10 - Severe
Medical History
Please check any conditions you currently have or have had in the past:
High Blood Pressure
Low Blood Pressure
Diabetes
Heart Conditions
Asthma
Cancer
Seizures
Stroke
Pacemaker
List any significant surgeries or hospitalizations:
Medications & Allergies
Current Medications/Supplements
Allergies (Drugs, Food, Environmental)
Lifestyle Factors
Dietary Habits
Exercise Routine
Sleep Quality (hours/night)
Stress Level (1-10)
Verification
I verify that the above information is accurate to the best of my knowledge.
Signature (Type name for digital signature)
Date
