Patient Health History Form Step 1 of 4 25% Name:*Date of Birth:* MM DD YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Cell Phone:Home Phone:Reason for your visit today?Past Medical History:ArthritisCancer(list type below)Cyst on ovariesDepressionType 2 diabetesEpilepsy/seizuresHeadachesHeart problemsHeart surgeryHigh blood pressureInsomniaPsychiatric diseaseProstate problemsAnxietyCOPD, lung problemsStrokeHypothyroidHashimotoHigh cholesterolKidney stonesFatty liverSleep apneaPost-menopausalOvarian cystPlease select all that apply to you, explain below if necessary: Explain Medical History AbovePast weight history:Diet pillshCG dietGestational diabetesHistory of weight loss surgerySpecial dietsPlease select all that apply to you, explain below if necessary: Explain Weight History AboveWhat is your heaviest weight?For men considering testosterone replacement therapy; have you have testosterone replacement in the past?Previous Surgeries or injuries: Please list past surgeries or injuries with approximate date: Medications: Please list any medications you are taking with dose and frequency:Allergies: Please list any allergies that you have:Social HistoryDo you drink alcohol? Yes No If yes, how much / week?Do you use tobacco? Yes No If yes, how much / day?Do you drink coffee? Yes No If yes, how many cups / day?Do you drink soda? Yes No If yes, how much / day?Do you drink sweet tea? Yes No If yes, how much / day?Do you use recreation drugs? Yes No NO If yes, what type and frequency?Family History: Do you know of any blood relative who has or had:AsthmaAneurysmBrain TumorCancer(describe type below)DiabetesEpilepsy/SeizuresHeadachesHeart ProblemsHigh blood pressureKidney diseaseLung diseaseMigraineMultiple SclerosisPsychiatric DiseaseStrokeThyroidNone As you review the following list, please check any problems check any problems or condition that you are experiencing or have experienced. If you do not have any of the problems listed in the section please check none. General HealthGood general healthRecent weight changeLoss of appetiteFatigueFever/chillsAllergyDrug allergiesFood allergiesHay feverOther:NoneExplain Other above:Ears, Nose, Mouth, ThroatDifficulty swallowingEarachesLoss of hearing/ deafnessLoss of smellLoss of tastePainful chewingRinging in earsSinus infectionSores in mouthNoneOtherExplain Other above:EyesBlind spotsBlurred visionDouble visionLoss of visionGlaucomaInjuryPainNoneOtherExplain Other above:GastrointestinalBlood in stoolsIncreasing constipationNauseaPainful bowel movementsPersistent diarrheaStomach or abdominal painUlcerVomitingNoneOtherExplain Other above:GenitourinaryBlood in urineFemale: irregular periodsFemale: #pregnancies / #miscarriages(Fill out below)Female: vaginal dischargeKidney stonesMale: prostate diseaseMale: testicle painPainful or burning urinationSexual difficultySexually transmitted diseaseUrgency with urinationUrine retention/incontinenceNoneOtherNumber of Pregnancies and MiscarriagesExplain Other above: Heart and LungsPain in chestHigh blood pressureHigh cholesterolIrregular heart beatNoneOtherExplain Other above:Muscles/Joints/BonesBack painDifficulty walkingJoint painJoint stiffness or swellingMuscle pain or tendernessNeck painNoneNeurologicalBalance troubleBlack outs/loss of consciousnessDifficulty speakingDifficulty walkingFacial droopingHeadachesInjury to the brain or spineLight-headed or dizzinessMemory lossMental ConfusionMigrainesMini strokeNeuropathyNumbness or tinglingParalysisStrokeTremorsWeaknessNoneOtherExplain Other above:PsychiatricDepressionAnxietyEating disorderNoneOtherExplain Other above:PulmonaryAsthmaBlood in coughCancerChronic or frequent coughEmphysemaPneumoniaShortness of breathNoneOtherExplain Other above:SkinRash or itchingSun sensitivityHair lossColor changesNoneOtherExplain Other above:SleepSnoringSleepwalkingNightmaresDo you sleep well? Yes No Do you feel rested when you wake? Yes No Do you fall asleep during the day? Yes No
