New Patient Health History

Ted Suzelis, ND and Rachael O'Connell, ND

Please correct the errors described below.

Patient Information

Your Current Health Concerns

If you have a specific health condition, please describe it in detail. When was the very first time that you noticed your condition and describe carefully any factor that you suspect may have played a role in its onset and its continuation.

List in order of importance other health concern that are troubling you:

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What is your interest level in the following therapies?

Your Health History

(10 is highest and 1 is lowest)
(10 is highest and 1 is lowest)
(10 is highest and 1 is lowest)

What is your height?

Please list the 5 most significant, stressful events in your life, from the most recent to the most distant.

Medical History

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Which of the following do you currently use? (list how often, how much and how long for each)

Family History

Please list ages, health problems, and if deceased, age at death and cause of death.

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Personal Habits

Female Reproduction

Male Reproduction


Kidneys and Bladder


How long have you lived at your current location?

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