Health History
please print this out and complete before your appointment
Dr. Linda Kingsbury, 106 East Third St. #3A, Moscow, Idaho 83843
| Name | |
| Address | |
| phone numbers | |
| Birthdate/Place | |
| Occupation | |
| Last medical exam/Dr. | |
| Current/recent medications | |
| Past meds for more than 1 year | |
| Current nutritional supplements | |
| Current healers or counselors | |
| FOCUS | |
| Current health challenges | |
| How is your physical heath affected? | |
| How is your emotional heath affected? | |
| How is your mental heath affected? | |
| How is your spiritual heath affected? | |
| How is your sleep affected? | |
| How is your social life affected? | |
| MEDICAL HISTORY | |
| height/weight | |
| Allergies | |
| Hospitizations/Operations | |
| WOMEN/PMS/Menopause symptoms/other | |
| MEN/prostate/other | |
| Health of your CHILDREN/ do they live with you? | |
| LIFESTYLE | |
| How do you feel about the foods you eat? | |
| Do you have any food or other cravings? | |
| Addictive behaviors? past/present (circle) | Do you use caffeine/nicotine/alcohol/marijuana/other |
| Do you sleep well? | |
| What type of exercise do you do? | |
| Where does the stress in your life come from? | |
| What do you do for fun/hobbies/recreation? | |
| Religious affiliation | |
| Spiritual Practices | |
| Favorite Season | |
| Do you have any pets? | |
| Are you exposed to environmental toxins in your work or home? Now/past | |
| Anything else that you think would be helpful as I teach you to build your own health? |
Please fill out the form below for 3-5 days and bring to your appointment.
Use as many pages as it takes.
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Time of Day |
Please list all Medications – Vitamin Supplements – Foods Snacks - Beverage Intake |
How you are feeling emotionally at the time of ingestion |
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Contact:
Dr. Linda Kingsbury
106 East Third St. # 3
Moscow, Idaho 83843
208-883-9933
Email: drlindak@earthlink.net
To order products and services