Integrative health analysis

HEALTH UNLIMITED--BEYOND THE BASICS
INTEGRATIVE HEALTH ANALYSIS
Name: _____________________________________ Date: _________________________
Address: _______________________________________________________________________
City: ________________________________________ State: ________ Zip: ________________
Date of Birth: _________ Age: _______ Email: ____________________________________
Home Phone: _________________________Work/Cell Phone: _________________________
Height: __________ Weight: ___________ Wt 1 year ago: ________ 5 years ago:__________
____Single ____Married ____Divorced ____Widowed
Occupation: ____________________________________ Full Time  Part Time 

Living situation: Alone  Friends  Partner/Spouse  Parents  Children  Pets 
Have you traveled outside the US & Canada in the past 2 years? Where?_______________
How did you hear about Health Unlimited? ___Web ___Friend ___Health Care Provider
Please list your major health concerns in order of importance:
Duration?
1.______________________________________________________________________________
2.______________________________________________________________________________
3.______________________________________________________________________________
4.______________________________________________________________________________
5.______________________________________________________________________________
Doctors, Health care providers or Consultants you are currently working with:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Major health problems, including operations (with dates):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
When was your last physical exam? ______________ Last Dr. appointment? __________
Recent medical tests with results: _________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Please list all herbs, vitamins, and dietary supplements you are currently taking, including
dosage and frequency: (take additional space on back or at the end of form if needed)
Name & reason for taking:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Please list all medications you are currently taking (including aspirin, antacids, etc.)
indicating whether they are over the counter (OTC) or prescription, including dosage and
frequency: (take additional space on back or at the end of form if needed)
Type/Brand & reason for taking:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Please list all medications, herbs, foods, environmental factors, to which you have a
known allergy:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you ever followed a specific diet? Yes No Are you following one now? Yes No
If so, which one, for how long, and why?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
NUTRITIONAL INFORMATION
Describe your typical meals & snacks below---think back over the past several weeks. Please be
as specific as possible. For example, instead of “oil” note the type of oil, such as olive, corn, etc.
Instead of “bread” list whether it is white or whole grain, etc. Instead of “vegetables,” list the
type of vegetable, how it was prepared, whether canned, frozen, or fresh, etc. Please include
the type and quantity of al beverages (two cups of orange juice, one cup of coffee, etc.).
Breakfast:______________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ Morning snack(s):_______________________________________________________________
_______________________________________________________________________________ Lunch:_________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ Afternoon snack(s):______________________________________________________________
_______________________________________________________________________________ Dinner:_________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ Evening snack(s):________________________________________________________________
_______________________________________________________________________________
Daily water consumption (number of glasses/day): __________ Tap—Filtered—Bottled—RO
What beverages do you usually consume? (Including al types of soda, tea, coffee, energy
drink, etc.)
_______________________________________________________________________________
_______________________________________________________________________________
How many times per week do you eat fast food or at a restaurant? _______________________
What are your favorite restaurants/fast food places? ___________________________________
How many times per week do you eat at home (home-cooked food)? ____________________
What are your favorite foods? ______________________________________________________
What is your diet staple/diet habit that would be most difficult to give up? ________________
Do you have any recurring food cravings such as salt, starch, sugar, chocolate, etc.? Please
list below, including time of day or month:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ FAMILY HISTORY
Please describe any relevant or major health related issues (cancer, mental illness, diabetes,
metabolic syndrome, heart disease, stroke, high blood pressure, arthritis, digestive issues,
depression, allergies, asthma, osteoporosis, addiction, headaches/migraines, kidney
disease, obesity, thyroid disease, bleeding tendency, eczema, psoriasis…):
Mother: ______________________________________________________________________
Father: ______________________________________________________________________
Sister(s): _____________________________________________________________________
Brother(s): ___________________________________________________________________
Maternal Grandmother: _________________________________________________________
Maternal Grandfather: _________________________________________________________
Paternal Grandmother: ________________________________________________________
Paternal Grandfather: _________________________________________________________
Activity Level (circle one): Sedentary--little or no exercise Light activity--exercise 1-3
X/week Moderate activity--exercise 3-5 X/week Very active--exercise 6-7 X/week
Extremely active--hard daily exercise or physically demanding job
Type of Activity?
Duration?
_______________________________________________________________________________
_______________________________________________________________________________
Typical bedtime:______ Typical hours of sleep per night:______ Do you feel rested upon
waking? Yes No Are you satisfied with your energy levels? Yes Sometimes No
On a scale of 1 (I feel sick) to 10 (I feel fantastic), where would you rate yourself? _________
Do you use tobacco? Yes No In past If yes, how much? _______/day
Do you drink alcohol? Yes No If yes, how much? ________ How often? _________
How many hours of television do you watch in a week? _______________________________
Do you use artificial sweeteners? Yes No Type:______________________________
Do you have regular bowel movements? Yes No How many times a day? _____________
Is it ever difficult to move your bowels? Yes No
Have your bowel habits changed recently? Yes No

Please list approximate dates and describe the nature of any traumatic experiences you
have had in the past 7 years (divorce, surgery, end of a relationship, loss of job, change of
residence, injury, illness, miscarriages, death of a loved one, etc.):
YEAR EVENT
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________ Please use this space to add any other information about yourself that you think will be
helpful:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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On a scale of 1 (low) to 10 (high), how stressful is your:
Work _______
Health Status ________
Social/Family Situation ________
MEDICAL HISTORY
List all major health problems including any operations:
PROBLEM YEAR
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________ GENERAL HEALTH
Cardiovascular
Muscles/Joints

Respiratory
Urinary/Kidney
Gastro-Intestinal

Eyes, Ears, Nose and Throat
 Ear aches

General
 Fatigue

Male Reproductive
 Burning/discharge

Female Reproductive
Age of first period: ___

Contraceptive/Pregnancy History (Designate if used in past)
 Birth Control Pills
Please list each pregnancy you have had, including miscarriages:
____________________________________________________________________________________
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____________________________________________________________________________________
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CURRENT STATE OF EMOTIONS AND SPIRITUAL WELL-BEING
Please check all those that describe you: I am often not able to express my emotions. I am often stressed out and not able to cope properly. Even though I’m in a relationship, I often feel lonely. I often feel anxious and nervous for no good reason. I don’t sleep well at night and have a hard time waking up in the morning. I often suffer from bad dreams and nightmares. There are many things I’d like to change in my life--I just don’t have the means. I have very low energy and often feel exhausted mentally and physically. I don’t enjoy my work and would rather be doing something else. I find my children irritating and hard to relate to. I often become angry with people and feel guilty about it later. I have a hard time letting go of the past. I don’t look towards the future with much enthusiasm. I am not able to concentrate for extended periods of time. My outlook is more negative than positive. I spend a great deal of time worrying about what people think about me. I have a great sense of humor and love a good joke. I have plenty of energy to do all the things I want. I sleep well at night and feel rested in the morning. I can concentrate on the task at hand for as long as it takes. I am able to express anger constructively. I practice meditation or other relaxation techniques. I try to maintain peace of mind and tranquility. I have many close friends that I can always count on. I accept full responsibility for my actions. I trust my intuition and believe that things happen for a reason. I do not harbor any resentment from the past. I can feel completely fulfilled even if I’m alone. I have many hobbies and interests to keep me preoccupied. How I see myself is more important than how others see me. I often go out of my way to help others.

Source: http://www.healthunlimited.biz/files/54447322.pdf