This document is a health history form for Better Living Clinic. It collects information such as name, date of birth, address, emergency contact, allergies, health concerns, surgeries, current medications, reason for visit, area of discomfort, exercise habits, diet, alcohol and tobacco use, and drug use from the client. It also includes sections for the clinic to track height, weight, blood pressure, and notes over multiple visits. The form disclaims that Better Living Clinic is not a medical facility and specializes in alternative care methods.

1. Better Living Clinic Health History
Referred by:_____________________________________​_
Name: (First, Last): DOB (day & month):
Address: Number:
Email: Birthplace:
Religion (optional):
Occupation (optional):
Last Physical Exam:
Age Range:
❏ 18-39
❏ 40-60
❏ 60 & wiser
Emergency Contact (name & number):
List Allergies, health concerns, surgeries and current medications:
Reason for Consult:
In what part of your body is there significant discomfort?
For Office Use Only- Better Living Clinic visitation log
Date Height Weight BP Observations & Notes
Date Height Weight BP
Date Height Weight BP
Date Height Weight BP
Date Height Weight BP
Date Height Weight BP
Date Height Weight BP
Date Height Weight BP
Date Height Weight BP

2. Better Living Clinic Health History
Exercise
❏ Sedentary
❏ Mild
❏ Occasional
❏ Regular vigorous exercise
Caffeine
❏ None
❏ Coffee
❏ Tea
❏ Cola
Diet
❏ Yes
❏ No
❏ Average meals/day ________
Fat intake
❏ Hi
❏ Lo
❏ Medium
Salt Intake
❏ Hi
❏ Lo
❏ Medium
Alcohol
❏ Yes
❏ No
❏ Drinks/Week _________
❏ Blackouts
❏ Binge drinking
Tobacco
❏ Cigarettes/Cigars/Pipe
❏ Chew
❏ No
❏ Quit # of years______
Drugs
❏ Recreational drugs?
❏ Have you ever given yourself street drugs
with a needle?
❏ No
Disclaimer: ​.By completing this form you agree that that Better Living Clinic is not a medical facility. We are a wellness center that
specializes in alternative care methods. Please consult with your medical doctor.Better Living Clinic is allowed to use your contact
information.​ Client Signature:​_____________________________________________________
Additional Notes/Concerns-Office Use Only
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