Health History Questionnaire ©
Dr. Glenn Wilcox LLC
Please fill out this questionnaire. It will help Dr. Wilcox provide you with a complete holistic, integrated medical evaluation.
Although it is 10 pages, most of it is checkboxes. However, the time you invest will help Dr. Wilcox better understand your
health issues and will save you time and fees during your initial consultation. If you have medical records, including test
results or imaging reports from the last year or two, please bring those with you or send them to us so that Dr. Wilcox can
review them during your initial consultation as well as avoid repeating tests that have been done recently.
Dr. Wilcox is the only person who will review this information. This information may only be shared or disclosed as
detailed in our Notice of Privacy Practices as required by HIPPA. If you have questions, please ask. If there is anything
you wish to bring to our attention that is not asked on this form, please note it in the COMMENTS section at the end, or
attach it. Copying this questionnaire for your own records may be wise. PLEASE PRINT CLEARLY.
Name
Today’s Date
Address
City
Mobile Phone
Home Phone
My Primary Phone is r Cell r Home r Work
Sex r Male r Female
Weight
State
Work Phone
Email
Birth Date
Height
Zip
Social Security #
Married r Yes r No
Driver’s License/State
In an emergency please notify
Mobile Phone
Home Phone
Work Phone
How did you find out about us?
List all doctors and health professionals you are currently consulting.
Doctor or Health Professional
Specialty
Phone
Describe your Single Main Health Issue. Other issues can be described on the next page.
If you have been given a diagnosis for this problem, what is it?
When, specifically, did this problem begin?
What type of treatment have you tried and was it helpful?
To what extent does this problem interfere with your activities such as work, exercise, recreation, hobbies, sleep or sex?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 1 of 10
Please list in order of importance the Other Health Issues that concern you.
Health Issue
How often does it occur?
How severe?
How long have
1-10, 1 is low
you had it?
List all allergies to prescription and nonprescription drugs.
List all significant allergies to foods or chemicals.
Please list all prescriptions medications at the top, followed by nonprescription medications and then healthcare
supplements (vitamins, minerals, herbs, etc.) you are currently taking.
Name
Reason For Using It
How Much?
How Often?
How Long?
Ever been on the following for a prolonged time? Print “Current” in the “Age” column if you are currently using them.
Medication
Age
How Long?
Antibiotics
Antacids, heartburn medicines (Tagamet, Zantac, etc.)
Steroids (Prednisone, Cortisone, Nasal Spray, Cream or Shots)
Pain Medicines (Narcotic Pain Meds, Acetaminophen, NSAIDs - Ibuprofen, etc.)
Osteoporosis/osteopenia medicines (Fosamax, Actonel, Boniva, etc.)
Chemotherapy drugs
Radiation treatment for cancer
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 2 of 10
HEALTH HISTORY CHRONOLOGY CHART
List, in chronological order by age, when each health issue started or a medical condition was diagnosed,
hospitalizations, surgeries, biopsies, infections (other than colds or flu unless significant), significant illnesses,
significant injuries, immunizations, dental fillings, crowns, root canals, as well as pregnancies, miscarriages and
abortions. Please try to be as complete as possible because this information may be critical to unraveling your
case. Start at as early an age as possible.
Age
Health Issue
Has your Mother (M), Father (F), Grandmother (GM), Grandfather (GF), Sister (S), Brother (B), Aunt (A) or Uncle (U) had
any of the following? Put the appropriate letters (M, F, GM, GF, S, B, A, U) beside any checked box.
r Heart attack
r Skin cancer
r Osteoarthritis
r Heart disease
r Lung cancer
r Rheumatoid Arthritis
r Congestive heart disease
r Cancer, other
r Autoimmune disease
r Stroke
r Asthma
r Osteoporosis
r High blood pressure
r COPD
r Alzheimer’s, Dementia
r Diabetes
r Emphysema
r Parkinson’s, Tremors
r Breast cancer
r Lung disease, other
r Psychological problems
r Ovarian cancer
r Liver disease
r Alcohol addiction
r Colorectal cancer
r Nephritis
r Drug addiction
r Prostate cancer
r Kidney disease, other
Describe other health problems of note in your family?
Describe any genetic problems?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 3 of 10
Please check the appropriate box if you have recently or currently had problems with any of the following. If any
of the problems was a major concern in the past, check the box and write the year it was a problem to the right of
the problem. Each category is arranged to read from top to bottom and then left to right.
GENERAL
r Anemia
r Always fatigued
r Fatigue easily
r Sudden drop in energy
r Chronic fatigue syndrome
r Perspire easily without exertion
r Perspire with difficulty or not at all
r Often “sick” as a child
r Recent weight loss
r Recent weight gain
r Seldom thirsty
r Often thirsty
Was your birth unusual? r Prolonged r Forceps r Cesarean r Other (describe)
GASTROINTESTINAL SYSTEM
r Constipation
r Hard stool
r Difficulty passing stool
r Bowel movements feel incomplete
r Frequent laxative use
r Diarrhea
r Traveler’s diarrhea
r Loose stool
r Erratic bowel movements
r Foul smelling stool
r Undigested food in stool
r Blood in stool
r Black stool
r Mucus in stool
r Celiac disease
r Gluten sensitivity
r Irritable bowel syndrome
r Spastic colon
r Crohn’s disease
r Colitis or ulcerative colitis
r Diverticula
r Diverticulitis or diverticulosis
r Intestinal polyps
r Hemorrhoids
r Intestinal gas
r Flatulence
r Belching
r Abdominal bloating
r Abdominal pain or cramping
r Stomach pain or cramping
r Stomach acidity
r Heartburn
r Indigestion
r Gurgling noise in stomach
r Nausea
r Vomiting
r Ulcer
r Hiatal hernia
r Bad breath
r Bitter taste in mouth
r Gallstones
r Poor appetite
r Excessive appetite
r Food allergies
r Parasites
How often do you have a bowel movement?
Any other problems with your digestive system or bowel movements?
EARS, NOSE, THROAT, MOUTH & DENTAL
r Congestion in ears
r Difficulty swallowing
r Ear infection or earache
r Lump or pit in throat
r Ringing in the ears
r Sore throat or strep throat
r Difficulty hearing
r Tonsillitis
r Deafness
r Swollen lymph nodes
r Head cold
r Dry mouth
r Nasal congestion
r Excessive saliva or drooling
r Runny nose
r Jaw tension or clicking (TMJ)
r Sneezing
r Grinding teeth
r Allergies
r Gum problems
r Sinus congestion or pain
r Bleeding gums
r Sinusitis or sinus infection
r Sores in mouth
r Nose bleeds
r Cold sores/fever blisters (HSV1)
r Facial pain
r Sores around lips
r Decreased sense of smell
r Dental infections
r Frequent dental cavities
r Dentures
r Metallic taste in mouth
r Geographic tongue
r Sores on tongue
r Center crack in tongue
r Cracks in tongue
r Scalloped edges on tongue
r Pale tongue
r Red tongue
r Purple or dark tongue
r Dry tongue
r Thin white coat on tongue
r Thick creamy coat on tongue
r Red spots on tongue
If you have root canals, how many and in which teeth?
Any other problems with your ears, nose, throat, mouth or teeth?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 4 of 10
RESPIRATORY SYSTEM
r Chronic cough
r Dry cough
r Tight rattling cough
r Loose productive cough
r Cough thick, sticky colored phlegm
r Cough thin, watery clear phlegm
r Bronchitis
r Pneumonia
r Pain with deep breath
r Tuberculosis
r Cough up blood
r Emphysema
r Shortness of breath
r Wheezing
r Asthma – difficult exhaling
r Asthma – difficult inhaling
r Asthma – worse with exertion
r COPD
Any other problems with your lungs or breathing?
IMMUNE SYSTEM
r Flu
r Recurrent fevers
r Frequent colds
r Chills
r Not breast fed
r Cancer
r Hepatitis
r Mononucleosis
If you have a chronic viral, bacterial or fungal infection, what is it?
If you have an autoimmune problem, what is it?
Have you recently had any immunizations?
Any other problems with your immune system?
SLEEP
r Difficulty falling asleep
r Shallow sleep
r Dream disturbed sleep
r Wake at night – thinking
r Wake at night – mind empty
r Nightmares
r Difficulty waking in morning
r Wake up not refreshed
r Sleepy in the afternoon
r Need to take naps
How many hours do you usually sleep in 24 hours?
r Narcolepsy
r Sleep too much
r Sleep too little
r Sleep apnea
r Snoring
During what hours do you sleep?
Any other sleep related problems?
SKIN HAIR & NAILS
r Rashes
r Hives
r Itching
r Eczema
r Psoriasis
r Shingles (herpes zoster)
r Herpes virus 1 (HSV1) - oral
r Pimples or acne
r Boils
r Ulcerations or sores
r Infections or inflammations
r Recent moles
r Recent change in mole
r Warts
r Dry skin
r Cracked skin on hands
r Cracked skin on feet
r Moist palms
r Moist feet
r Fungus on skin
r Hair loss
r Dandruff
r Dry hair
r Pale lusterless nails
r Lengthwise ridges on nails
r Crosswise ridges on nails
r White spots on nails
r Thick nails
r Fungus under nails
r Split nails
r Weak, brittle or flaking nails
r Clubbing (convex) nails
r Spooning (thin & concave) nails
r No moons
r Large moons
r Nail biting
Any other problems with your skin or hair?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 5 of 10
CARDIOVASCULAR & BLOOD
r Irregular heartbeat/arrhythmia
r Heart valve problems (prolapse)
r Rapid heartbeat or palpitations
r Angina, chest pain or pressure
r Back pain
r Shortness of breath
r Coronary artery disease
r Heart disease
r Heart attack/myocardial infarction
r Known heart disease
r Known vascular disease
r Heart Surgery
r Family history of heart disease
r Post menopausal
r High cholesterol
What is your blood type?
r A pos.
r High blood pressure/hypertension
r High cholesterol
r High triglycerides
r Stroke
r Blood clots
r Phlebitis
r Varicose veins
r Hemochromatosis/iron overload
r Bruise easily
r Hemophilia
r Anemia
r Edema
r Swelling of hands or arms
r Swelling of feet or legs
r Low cholesterol
r A neg.
r AB pos.
r AB neg.
r Cold hands
r Cold feet
r Hot hands or palms
r Hot feet or soles
r Generally too cold
r Generally too hot
r Rheumatic fever
r Current smoker
r Former smoker
r Sedentary lifestyle
r Overweight
r Diabetes
r Low blood pressure
r Blackouts or fainting
r High Triglycerides
r B pos.
r B neg.
r O pos.
r O neg.
If you have ever had a blood transfusion, when?
MUSCULOSKELATAL SYSTEM
r Neck pain or stiffness
r Shoulder blade pain
r Shoulder joint pain or stiffness
r Rotator cuff tear or syndrome
r Upper arm pain or stiffness
r Elbow pain or stiffness
r Wrist pain or stiffness
r Carpal tunnel syndrome
r Numbness or tingling in hands
r Hand or finger pain or stiffness
r Upper back pain or stiffness
r Mid back pain or stiffness
r Low back pain or stiffness
r Scoliosis
r Sacroiliac pain or stiffness
r Hip joint pain or stiffness
r Pain into thigh or upper leg
r Pain into calf or lower leg
r Weak legs
r Knee pain or stiffness
r Weak knees
r Leg or calf cramping
r Restless leg syndrome
r Ankle pain or stiffness
r Weak ankles
r Foot or toe pain or stiffness
r Numbness or tingling in feet
r Muscle spasms or cramps
r Muscle weakness
r Paralysis
r Stiff all over
r Osteoarthritis
r Rheumatoid arthritis
r Osteopenia
r Osteoporosis
r Tendonitis
r Fibromyalgia
If you have pain, where is it located?
Is the problem helped by r pressure r heat r cold r dry weather r hot weather r other
Is the problem aggravated by r pressure r heat r cold r damp weather r windy weather r other
NEUROLOGICAL SYSTEM & HEAD
r Dizziness or loss of balance
r Seizures or epilepsy
r Alzheimer’s
r Dementia
r Parkinson’s
r Multiple sclerosis
r Lack of reflex
r Unusual lack of coordination
r Migraine headache
r Cluster headache
r Headache
r Concussion
If you have numbness, tingling or abnormal sensation, where is it?
Any other problems with your head or neurological system?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 6 of 10
EYES
r Nearsighted (myopia)
r Farsighted (hyperopia)
r Astigmatism
r Glaucoma
r Cataracts
r Poor night vision
r Macular degeneration
r Sensitivity to light
r Blurred vision
r Floating spots
r Pressure behind eyes
r Eye pain
r Dry eyes
r Watery eyes
r Itchy eyes
r Red eyes
r Conjunctivitis
r Need eyeglasses
r Blindness
r Decreased vision
r Persistent urge to urinate
r Frequent urination
r Difficulty urinating
r Decreased flow of urine
r Flow does not stop quickly
r Dribbling
r Bed wetting
r Pain/burning when urinating
r Pain/discomfort in bladder area
r Blood in urine
r Bladder infection
r Kidney infection
r Kidney stones
r Kidney disease
r Night sweats
Any other problems with your eyes?
URINARY SYSTEM
r Scanty or small amount of urine
r Dark urine
r Strong smelling urine
r Cloudy urine
r Excessive amount of urine
r Clear urine
r Unable to hold urine
r Urgency to urinate
How many times do you urinate in 24 hours?
How many times do you wake at night to urinate?
Any other problems with your urinary system?
FEMALE SEXUAL SYSTEM, PREGNANCY & GYNECOLOGICAL
Number of pregnancies
r Painful periods
Number of births
r Cramping before start of period
Premature births
r Cramping after start of period
Miscarriages
r Low back ache with period
Abortions
r Endometriosis
Difficult deliveries
r Spotting between periods
Cesarean sections
r Missed periods
Age of children
r PMS
Age at first menses
r Premenstrual irritability
Last period starting date
r Premenstrual emotional sensitivity
Duration of flow
r Premenstrual bloating
Days between periods
r Premenstrual fluid retention
Age at start of menopause
r Premenstrual headache
r Have not begun to menstruate
r Premenstrual constipation
r Hysterectomy
r Premenstrual diarrhea
r Hot flashes
r Premenstrual breast sensitivity
r Irregular cycle
r Breast sensitivity during period
r Heavy flow
r Mid-cycle breast sensitivity
r Light flow
r Breast sensitivity
r Clots
r Vaginal discharge
r Dark or brownish blood
r Vaginal infection
r Light colored or pale blood
r Abnormal PAP
r Uterine fibroids or cysts
r Ovarian cysts
r PCOS
r Breast cysts or lumps
r Fibrocystic breasts
r Pelvic inflammatory disease
r IUD
r Currently use birth control pills
r Previously used birth control pills
r Infertility
r Cannot maintain pregnancy
r Trying to become pregnant
r Pregnant
r Nursing
r Nausea or morning sickness
r Pain/discomfort during intercourse
r Inability to orgasm
r Difficulty achieving orgasm
r Low sexual energy
r Excessive sexual energy
r Sores on genitals
r Herpes simplex virus 2
Any other gynecological or pregnancy problems?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 7 of 10
MALE SEXUAL SYSTEM
r Enlarged prostate
r Prostatitis
r High PSA
r Prostate cancer
r Low sperm count
r Inability to maintain an erection
r Premature ejaculation
r Ejaculation during sleep
r Inability to achieve orgasm
r Pain/discomfort during intercourse
r Low sexual energy
r Excessive sexual energy
r Priaprism (persistent erection)
r Swollen testicles
r Sores on genitals/ Herpes simplex virus 2
Any other problems with your genitals?
ENDOCRINE SYSTEM & HORMONES, GENERAL
r Hypothyroid
r Low cortisol
r Hashimoto’s thyroiditis
r Addison’s disease
r Hyperthyroid
r Hyper adrenal function
r Grave’s disease
r High cortisol
r Goiter
r Low DHEA
r Wilson’s temperature syndrome
r Low testosterone
r Adrenal insufficiency
r Low estrogen
r High estrogen
r Low progesterone
r High blood sugar
r Diabetes
r Insulin resistance (Metabolic syndrome)
r Hypoglycemia
Any other problems with your endocrine system or hormones?
PSYCHOLOGICAL
r Depression
r Lack of motivation
r Frequently angry or irritated
r Tend to repress emotions
r Overly emotional
r Mood swings
r Difficulty relaxing
r Hyperactivity
r Manic episodes
r Obsessiveness/compulsiveness
r Sadness or grief
r Frequent crying
r Anxiety or fear
r Panic attacks
r Difficulty handling stress
r Indecisiveness
r Poor memory
r Difficulty concentrating
r Confusion or lack of clarity
r Nervous breakdown
r Suicidal thoughts
For the following area use an “S” for Satisfying, “A” for Acceptable and “P” if it might be a Problem area.
Spouse
Children
Sex Life
Finances
Work
Life In General
Have you recently had an unusually stressful experience such as divorce, loss of job, severe illness or death?
Is there a constant stress in your life at work, with your family, with your friends?
Generally, how would you rate your stress level? r Low r Moderate r High
Have you ever been attacked or abused? r Physically r Psychologically r Sexually
Any other psychological or emotional concerns?
TOXICITY
How many mercury amalgam silver fillings do you have now?
How many have you had replaced?
Have you ever had an unusual exposure to any of the following toxins? r Mercury r Lead r Cadmium r Arsenic
r Uranium r Radiation r Radon gas r Pesticides r Herbicides r Toxic Chemicals r Petrochemicals r Other
If you have had an unusual toxic substance exposure, describe what and when?
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 8 of 10
FOOD & DRINK
List any food allergies.
Are you a vegetarian or vegan? Please describe.
List any dietary restrictions.
List any strong food cravings.
Do you salt your food? r Yes r No
Do you think you might have an eating disorder? r Yes r No
What kind of water do you drink? r Municipal r Well r Spring r Filtered r Reverse Osmosis r Distilled
Approximately how many ounces of water do you drink a day?
Do you drink soft drinks? r Yes r No
How many ounces a day?
SUBSTANCES
If you drink alcohol, what do you drink, how much and how often?
Have you ever had a problem with alcohol or drugs? r Yes r No
If you smoke or chew tobacco, how much and how often?
Have you ever smoked or chewed tobacco? r Yes r No
How much?
How long?
Any other substance issues?
EXERCISE
Type of exercise
How long do you exercise?
How often
WORK & TRAVEL
Describe the work you do, or did if you are retired.
Where have you traveled outside the U.S.?
ELECTROMAGNETIC FIELDS (EMF)
Do you sleep with an electric blanket, electric mattress pad or waterbed heater? r Yes r No
Do you sleep with a cell phone or electric clock or other electronic device near you? r Yes r No
Do you leave your Wi-Fi network on during the night? r Yes r No
Is there a Smart Meter on your home or nearby neighbors home? r Yes r No
Do you live/work next to a cell tower? r Yes r No
Do you live/work next to high voltage power lines? r Yes r No
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 9 of 10
GENERAL HEALTH, DIET AND LIFESTYLE
Rate how you feel and function now compared to your “peak” years.
No Change
r
Energy level
r
Strength
r
Exercise endurance
r
Recovery from exercise
r
Reaction time
r
Muscle weakness, stiffness, aching
r
Joint stiffness, aching
r
Balance and equilibrium
r
Steadiness of hand
r
Memory
r
Mental quickness
r
Insomnia
r
Anxiety
r
Moodiness
r
Depression
r
Digestion
r
Sexual desire
r
Sexual function
r
Vision
r
Hearing
r
Height
r
Weight
r
Weight control
r
Water retention
r
Skin quality
Worse
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
Much Worse
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
COMMENTS
Use the following space to add anything else you think might be important for the doctor to know.
Health History Questionnaire © 2015 Dr. Glenn Wilcox LLC
Revised 04-17-15
Page 10 of 10