York Region Centre for Natural Health

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Date

Name

Birthdate

Gender

Chief Complaint - Location: where is the pain or problem?

Pain - Describe pain give rating of severity 1-5 (5 being the strongest)

Occurance - Does the pain or problem occur at a specific time?

Signs and Symptoms - Associated signs or symptoms:

Duration - How long have you had this issue? Date it started

What was going on in your life when this issue started?

Modifying Factors - What makes the problem/pain worse/better

Surgeries - Reasons for and date of surgery

Other Hospitalizations or Serious Illnesses - Reason and date

General Medical BackgroundVaccinations:Have hadWeight Gain: Weight lossExercise:

ExcerciseDailyWeeklyOther

Are there others substances that you us that are not listed