Personal Health History
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- Lizbeth Farmer
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1 Personal Health History Last Name First Female ( ) Birth Date Age MI Male ( ) Address Apt# City State Zip PATIENT INFORMATION Home Phone Cell Phone Work Number Marital Status Height Weight Goal Weight? Employer Emergency Contact Relationship Phone Physician Address Phone Who Referred You? Name This section is for the purpose of learning more about your health history. Please read and answer all of the following questions to the best of your knowledge. Reason for Consultation What health concerns and symptoms brings you to the clinic? What would you most like to achieve with this health consultation? Are you currently under the care of a physician/health professional for a medical/health condition? Yes No Physicians Name If yes, please list: 1
2 **Please check any medical conditions or health problems that you currently have or have had in the past? Past Medical History Seizures Disorder Heart Disease Recurrent sinus infection Chest Pain Seasonal allergies Irregular Heart Beat Emotional Illness High Blood Pressure Asthma Blood Clotting problem Chronic bronchitis Bleeding disorder Lung/breathing issues Stroke/vascular disease Chronic Indigestion Constipation/diarrhea Stomach Ulcers Hepatitis/Liver disease Intestinal Disease Kidney disease Skin problems/dermatitis Menstrual disorders Back Pain or Sciatica Reproductive problem Herniated Disc Prostate problems Neck pain Tendonitis Muscle or Joint Pain Chronic pain problems Carpal Tunnel Syndrome Shoulder problems Fibromyalgia Osteoarthritis Diabetes Rheumatoid Arthritis Thyroid disease Artificial joint/implant Osteoporosis/Osteopenia Cancer Psoriasis or eczema List any additional health problems not listed above: List any surgeries/operations you have had and when: - 2 P a g e
3 List any prescribed medications you are currently taking (or have taken in the recent past) Medication Name Date Started Date Stopped Dosage (# daily) (If any additional medications please attach a separate page with the above info) Nutritional supplements, vitamins, herbs, homeopathic remedies taken: Have you ever used Hormone Replacement Therapy or Anabolic Steroids? yes no Medication Allergies: Environmental/Food Allergies: Preventive Tests: Date of last test Results (if known) Cholesterol Bone density Colonoscopy Exercise stress test 3 P a g e
4 Family History (Write the relationship of the relative(s) with the disease on the adjacent lines) Heart Disease High Blood Pressure Diabetes Arthritis Skin disorders Breast Cancer Uterine/Ovarian Cancer Prostate Cancer Colon Cancer Other Cancer List any other disease/condition in the family and relationship WOMEN ONLY ARE YOU PREGNANT? First day of last menstrual cycle Date of last pap/pelvic/breast exam Results: normal abnormal Date of last mammogram Results: normal abnormal Do you perform monthly self-breast exams? Are you currently taking or have you in the past taken hormones or oral contraceptives? If yes, please list all hormones and oral contraceptives you have taken and when 4 P a g e
5 Have you ever had any problems or concerns about taking hormone replacement therapy? If yes list problems. How many pregnancies have you had? How many children? Have you had a hysterectomy? If yes, were your ovaries removed? Has your abdominal girth and weight been increasing? Have you had any menstrual irregularities? (if yes explain) MEN ONLY Date of last prostate exam: Are you concerned with loss of muscle mass, tone, or strength? Have you had problems with urination (decreased stream, frequent night urination) Do you perform periodic testicular self-examination? Has your abdominal girth and weight been increasing? Social History and Personal Health Habits General My health is: My physical fitness is: (Check all that apply) excellent good fair poor. excellent good fair poor Stress level: I am often sad and blue I am under a lot of stress I have difficulty dealing with stress I am fatigued all the time I practice meditation/relaxation techniques Dietary Habits I commonly consume: Coffee Regular soft drinks Candy/chocolate Chips/crackers I do not eat dairy/cheese No special diet habits Minimizes Carbs I try to eat a healthy diet Avoids red meat Minimizes fat Vegetarian Diet soda Emphasize fruits, grains, vegetables 5 P a g e
6 Exercise Habits No special exercise habits I routinely exercise hr(s) X/week Lift weights Aerobic exercise (jog/walk/treadmill) Swim Stretch/Yoga/Tai Chi/Chi Gong Tobacco Use Other I never smoked cigarettes or chewed tobacco I smoke packs of cigarettes per day. I quit smoking in (mo/year). I smoke cigars/pipe I have smoked for years I smoked packs/day for years I use/used recreational drugs When? What? Alcohol Use I never drink alcohol I drink occasionally or socially I regularly drink: 1-2 drinks/day more than 2 drinks/day more than 4 drinks/day Hobbies/Sports/Recreation List routine hobbies/sports/recreational activities EnVoque MD Consultation Terms 1. I understand that today s consultation is used to determine whether or not I am a candidate for care. 2. I understand that the consultation process does not establish me as a patient under EnVoque MD s care and there is no doctor-patient relationship or obligation. 3. I am aware that after the consultation, I may not be accepted as a patient. 4. I understand that your EnVoque MD Doctor is not able to and does not accept every case. 5. Please fill out all paperwork completely to the best of your knowledge. 6. It is necessary that you are under the care of a primary care physician. I have read, understand and accept the terms of this initial consultation. I agree that the statements above are true and accurate and I have disclosed all health issues to the best of my knowledge. Patient Signature Date A 24 hour notice of cancellation is required. If your cancellation is less than 24 hours or you do not show for your appointment a rescheduling fee will apply before for your next appointment. This is for the consideration of our patients that are waiting for a sooner appointment and allows us the necessary time to contact them with the sooner appointment availability. We thank you for understanding regarding this policy that has proven to be very successful in meeting our patient s medical needs. 6 P a g e
7 Consult/Practitioner comments on above: 7 P a g e
PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION Name (last, first, middle initial) Social Security Number Birth date
LONGEVITY WELLNESS CENTER 9426 Battle Street, Ste. 201 Manassas, VA 20110 PHONE: 703-272-8501 FAX: 703-272-8502 WEBSITE: www.longevitywellness.net PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION Name
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Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
Nutrition Packet INFORMATION FOR THE DAY OF YOUR APPOINTMENT
Nutrition Packet Enclosed is a packet of information for you to fill out and bring with you to your appointment. But first, a few important details before we meet: INFORMATION FOR THE DAY OF YOUR APPOINTMENT
ADVANCED NUTRITIONAL CONSULTING
ADVANCED NUTRITIONAL CONSULTING Steven Salyers DC MS CNS DACBN Certified Nutrition Specialist, Diplomat American Clinical Board for Nutrition Last Name: First Name: Street Address: City: State: Zip: Phone:
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY Today s Date: Name Date of Birth
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY 317-880-6825 Today s Date: Date of Birth Phone # Alternate # Age Height Current weight Significant other Name: Reason for