Medical History Form

Section 1: Personal Information

Name: ________________________________________________ Date: ___________________

Email: _____________________________________________ SS#: _______________________

Address: ______________________________________________________________________

City: ______________________________ State: ___________ Zip: _______________________

Home Phone: __________________________ Cell Phone: ______________________________

Fax: ______________________________ Date of Birth: ________________________________

 

Section 2: Medical Information

Primary Care Physician: __________________________________________________________

Physician Phone: ___________________________ Last Physical: _________________________

 

Height: _____________feet _____________ inches Weight: ____________________lbs

Smoker: ___________ Yes ___________ No

Alcohol: ___________ Yes ___________ No If so, how many times per week: ____________

 

Allergies:


 

Current Prescriptions:


 

Current Supplements (Vitamins, Herbs, Minerals):


 

Family History (Select diagnosed disorders/ diseases of immediate family members):

 

_____ Obesity _____ Osteoporosis

_____ Cardiovascular (heart) Disease _____ Emotional/ Mental Disorder

_____ Diabetes _____ Stroke

_____ Thyroid Disease _____ Blood Disorder

_____ Cancer What type? _______________ _____ Hypertension

_____ Lipid (cholesterol) Disease _____ Endocrine Disorder

 

Personal History (Select your personal diagnosed disorders/ diseases):

 

_____ Obesity _____ Osteoporosis

_____ Cardiovascular (heart) Disease _____ Emotional/ Mental Disorder

_____ Diabetes _____ Stroke

_____ Thyroid Disease _____ Blood Disorder

_____ Cancer What type? _______________ _____ Hypertension

_____ Lipid (cholesterol) Disease _____ Endocrine Disorder

_____ Depression/ Anxiety _____ Genital/ Urinary Disorder

_____ Ovarian Cysts _____ Kidney Disease

_____ Muscular/ Skeletal Disorder _____ Lung Disease

_____ Migraine Headaches _____ Fibromaylgia

_____ Liver Disease

 

For Women Only

Have you had a hysterectomy? _____ No _____Full _____ Partial Date: _________________

Reason: ___________________________ Date of last Menstrual Cycle: ___________________

Tubal Ligation: _____ Yes _____ No Are you currently pregnant: _____ Yes _____ No

How many times have you been pregnant: _____________ Given birth: _____________

Date of last Mammogram: ________________________ Abnormal: _____ Yes _____ No

If yes, please explain:


Date of Last Pap Smear: ____________________________ Abnormal: _____ Yes _____ No

If yes, please explain:


 

 

Severe

Moderate

Mild

None

Female Only

       
Vaginal Dryness        

Male Only

       
Erectile Dysfunction        

 

Night Sweats        
Dry Skin        
Dry Hair        
Hair Loss        
Weight Gain        
Unexplained Weight Loss        
Bladder Infections        
Yeast Infections        
Difficulty Concentrating        
Irritability/ Stress        
Mood Swings        
Breast Tenderness        
Nervousness        
Anxiety        
Migraines        
Insomnia        
Sex Drive Loss        
Fatigue        
Depression        
Muscle Atrophy (Loss)        
Cold/ Heat Intolerance        
Decreased Desire/ Ability to Exercise        
Painful Joints        
Decreased Energy/ Endurance        
Decreased Sense of Well Being        
Water Retention        
Exhaustion in the Morning        
Exhaustion in the Afternoon