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Individual ‘MINOR’ – History And Physical Form

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It is extremely helpful to have you prepare some information before your first appointment. This ensures that our visit is as thorough and useful as possible. These forms include a questionnaire, diet diary, disclosures and consent form. Please complete all pages of the questionnaire. You can fill out the diet diary for any 3 days in a row between now and your appointment.

Thank you for putting your time into this preparation and please remember to bring them with you to your appointment.


Past Medical History

Family History

Indicate any ailments which have affected your relatives. Do/did they have the same ailments as you? Possible ailments: AIDS, alcoholism, allergies, arthritis, asthma, cancer, diabetes, drug addiction, epilepsy, frequent colds, gonorrhea, gout, heart problems, mental illness, neurological problems obesity, pleurisy, pneumonia, skin problems, syphilis, thyroid problems, tuberculosis, ulcers, warts.

Social History

Review of Systems (ROS)

Patients are often asked to check any symptoms they currently have or have had in the last 6-12 months.