MD LONGEVITY CLIENT CONTACT INFORMATION. First Name: MI: Last Name. Billing Address: Street: City: State: Zip Code: Street: City: State: Zip Code:
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1 MD LONGEVITY CLIENT CONTACT INFORMATION First Name: MI: Last Name Billing Address: Street: City: State: Zip Code: Shipping Address (if different from billing address): Street: City: State: Zip Code: Phone Numbers: Please check your contact preference. Home: Cellular: Pager: Work: Fax: Private Fax Public Fax Date of Birth: Gender: Month: Day: Year: 19 Male Female Emergency Contact: First Name: Last Name: Address: City: State: Zip Code: Phone: Relationship: Whom may we thank for referring you? What are your favorite hobbies/interests?
2 MD LONGEVITY CONFIDENTIAL HEALTH HISTORY Today s Date: NAME: Birth date : / / Age: Marital Status: Level of Education: Current Occupation: Is your occupation enjoyable? Y / N Is it stressful? Y / N Is it fulfilling? Y / N Hazardous Material exposure? Y / N If retired, what was your main occupation? When did you retire? Are you happy in retirement? Y / N YOUR GOALS: What you hope to achieve in your participation in the MD Longevity Program? PRESCRIPTION & OVER the COUNTER PLEASE LIST ACTIVE MEDICAL PROBLEMS: medications you are currently taking: ALLERGIES: - DRUGS: FOODS: NUTRIENTS / SUPPLEMENTS you are taking: CONDITIONS: Check any other conditions you have ever had in the past, & indicate what year? AIDS / HIV+ Allergies / Asthma Anemia Alcohol / drug problem Anorexia / Bulemia Arthritis Atrial Fibrillation Anxiety / Panic Disorder Back pain Bleeding Disorder Candida / Yeast Cancer Specify: Chronic Fatigue Crohn s Disease Colitis Diabetes -Type: I II Depression Emphysema Epilepsy / Seizures Fibromyalgia Glaucoma Goiter Gout Hiatal Hernia / Reflux Heart Disease High cholesterol Irritable Bowel Hypertension / High BP Jaundice Kidney Disorder Kidney Stones Liver Disease Hepatitis Migraines Multiple Sclerosis Osteoporosis Pancreatitis Parasites Parkinson s Pelvic Infl Disease Pneumonia Polio Prostate Problem Rheumatic Fever Root canal Sinusitis Stroke / TIA Suicide Attempt Thyroid problem TMJ Tooth Abscess Tuberculosis Ulcers Urinary Infection OTHER: CURRENT or RECENT SYMPTOMS: Check any symptoms that you have noticed recently. Chest pain Blood in sputum Fainting / collapse Leg pain w walking
3 Nose bleeds Shortness of Breath Swollen ankles Snoring excessively Abdominal Pain Acid reflux Black tarry stools Bright blood in stool Difficulty swallowing Loss of appetite Persistent nausea Mood swings Kidney pain Blood in urine Frequency of urination Urgency of urination Change in headaches Double vision Dizzy / spinning Eye pain Bone pain Unusual bruising Prolonged bleeding Bloated Excessive thirst Rapid heart beat Other Symptoms: Recent change in bowel habit Weight loss - unexpected HOSPITALIZATIONS: Please include Surgeries, illnesses, severe accidents, births, miscarriages: Year: Procedure Reason: Outcome: FAMILY HISTORY: Please complete health Information about your family: Relation Age: State of health: Age at Death: Cause of death Check if your blood relatives had any of the following Disease: Relation to you: Father Arthritis / Gout Mother Asthma / Hay Fever Brothers Cancer: Where: Drugs / Alcohol Diabetes Heart Disease Sisters High Blood Pressure Osteoporosis Stroke Tuberculosis RECENT TESTS: HEALTH HABITS: If you have had any of these tests, please complete: Which substances do you consume: TEST: Dat Reason: Result: Substance How Much? Chest X Ray Caffeine cups,cans EKG Cigarettes packs / day x EGD (Stomach Are you interested in quitting? Y / N Colonoscopy Alcohol Type Amount Ultrasound Drugs Y N What Amount CAT Scan Chew tobacco Y N Amount Yrs MRI Scan Nutrasweet Servings per day: Bone Density Saccharin Servings per day: Other
4 FOR WOMEN: Date of 1 st day of last period: Birth control method: Are you pregnant? Y / N Date of last PAP test: normal / abnormal Date of last Mammogram: normal / abnormal Date of Menopause: Have you ever had an abnormal pap? Y / N When? Review this list of symptoms and check the ones that apply. PMS Hot flashes Sleep problems Uterine Fibroid Vaginal Dryness / Pain Mood swings Fibro-cystic Breasts Loss of interest in sex Painful Periods Ovarian Cysts Leak Urine Unusual vaginal discharge Irregular periods Painful periods Cramps / clots w periods Vaginal irritation Painful sex Spotting after menopause Increased fat around hips / thighs Endometriosis Problems w Infertility FOR MEN: Date of last prostate exam: normal / abnormal Review this list of symptoms and check the ones that apply:. Lowered interest in sex Erections less firm Difficulty in initiating urine stream Getting up at nite to urinate Enlarged prostate Can t maintain an erection Slowing urinary stream Problems w Infertility Bladder not emptying completely REVIEW THESE SYMPTOMS OF AGING AND CHECK THE ONES THAT APPLY. Thyroid Dry hair Infertility Migraines Losing hair Constipation Fluid retention Crave caffeine Dry coarse skin Diets don t work Cold hands & feet Elevated cholesterol Low body temperature Fatigue / Exhaustion Decreased memory Brittle unhealthy nails Unable to lose weight Daytime drowsiness Foggy / spacey mind Depression / Anxiety Low ambition / motivation Decreased concentration Fibromyalgia / Chronic fatigue Feel cold / dress more warmly Cardio-Respiratory: Palpitations Decreased stamina Decreased endurance Run out of breath sooner Easily exhausted with exercise Decreased ability and desire for exercise Adrenal: Palpitations Salt craving Sugar craving Panic attacks Muscle tension Easily frustrated Excessive hunger Prone to infection Low blood pressure Poor stress tolerance Low back pain (SI joints) Light headed on standing up Racing mind prevents sleep Need sunglasses in bright sun light Metabolism: Can not skip meals High blood pressure Headache w missed meal Cravings for sugar & carbs High cholesterol / triglyceride Increased fat around abdomen Prone to inflammation and bursitis Periods of low energy relieved w food Shaky / weak episodes Eating helps Jittery / irritable episodes Eating helps Alternating between high and low moods Alternating between sluggish and high energy
5 Skin / Integumentary: Dry skin Thin Lips Graying hair Skin blemishes Thin brittle nails Tendency to bruising Thinned skin hands, face, arms Thinning hair scalp, armpits, legs Wrinkling skin face, neck, hands & arms Sagging skin under eyes, arms, face, breasts Neuro-cognitive: Loss of esteem Feeling hopeless Feeling defeated Loss of confidence Vision deteriorating Hearing deteriorating Memory deteriorating Sense of powerlessness Decreased sense of well being Gastrointestinal: Feel full faster Slower digestion Fullness after meals Eat less / smaller meals Indigestion / Hyperacidity Burping or belching after meals Decreased sense of taste / smell Muscles/Joints: Osteoporosis Aches and Pains Loss of strength Body & joints stiff Balance deteriorating Coordination deteriorating Thinning muscles buttocks, arms, legs DIET: Are you on any specific diet? (Please specify: Successful? Y / N List which diets have been effective in the past: STRESS: Rate your current stress level: Extreme; High; Medium; Low (Please circle) How long has it been like this? You expect this to last a short medium long period of time. (please circle) Do you have a solution? Y / N Do you need help? Y / N EXERCISE: Please circle which you do. Aerobic Weights Walking Other: How long are your workout sessions? How many days / week? SLEEP: Please check the symptoms that you notice. Trouble getting to sleep racing mind Sleep not as restful / Wake up not rested Wake up through night feeling like you are choking or having a smothered sensation Your partner has noticed very heavy snoring during sleep Your partner has noticed that you stop breathing through the night with heavy snoring Daytime drowsiness or sleepiness especially with periods of inactivity Toss and turn through night / wake frequently through night Take a moment to reflect on your response to the following question: On a scale of 0 5 (5 being the strongest response), circle your response: How important and committed are you to a longevity program?
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City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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