Health History Questionnaire Mr. Mrs. Ms. Miss Last Name First Street Apt# City State/ Zip Code
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1 Health History Questionnaire Mr. Mrs. Ms. Miss Last Name First Street Apt# City State/ Zip Code DOB (MM/DD/YYYY) Social Security # Home Phone # Business Phone # Cell Phone # Fax # Address I am primarily interested in: Hormone Balancing Fatigue/Chronic Fatigue Nutrition Assessment Referred By: Print Ad Television Radio Internet Newspaper Friend Other My Desired Goals: List Allergies: (Medication, Food, Environmental) Last Physical Exam Date: List Surgeries/Dates: MEDICAL HISTORY Questions for Females Only Have You Ever Had or Do You Now Yes No Tuberculosis Treatment for gynecological (female) disorder? Shortness of breath A change of menstrual pattern? A chronic cough or cough at night Any abnormal Pap smears? Sinusitis/Hay fever Do you have irregular periods? Yes No Thyroid trouble or goiter Cataract or Glaucoma Do you have any symptoms before your periods (i.e.: PMS) Have your periods stopped? If yes, when? Numbness or tingling How old were you when your periods first began? Stomach, liver, intestinal trouble, or How many times have you been pregnant? ulcer Gall bladder trouble or gallstones How many live babies have you delivered? Jaundice or hepatitis (liver disease) How many miscarriages have you had? Rectal disease, blood in stool How many abortions have you had? Skin diseases (i.e. acne, eczema, psoriasis, etc) Frequent or painful urination MEDICATION LIST: Please list all prescriptions/supplements/herbals taken regularly Adverse reaction to meds/antibiotics Recent unexplained wt gain or loss Dizziness or fainting spells Prolonged bleeding Palpitation, pounding heart or abnormal heartbeat High or low blood pressure Depression or excessive worry AVCHHQ Copyright
2 PREVENTATIVE SERVICES ASSESSMENT Flex Sigmoidoscopy / Colonoscopy Rectal Exam Flu Shot Tetanus Shot Cholesterol Check Pneumovax (Pneumonia) Shot Pap Test Mammogram (For Women Only) Breast Exam by a Physician (For Men Only) Prostate Exam Testicular Exam Never < 1 year <1-2 year <10 years EXERCISE ASSESSMENT: Approximate your weekly exercise routine. Circle the most accurate response for you. In a week, how many times do you engage in aerobic exercise for 30 minutes or more? How often do you do exercises to build your strength, such as sit-ups, push-ups, or weight training? Never 1-2x/wk 3-4x/wk 5x/wkmore/wk Never 1-2x/wk 3-4x/wk 5x/wkmore/wk SEXUAL HEALTH ASSESSMENT: This Assessment measures your attitude towards sex and sexuality. Study the following statements and choose the most accurate response for you. Are you emotionally and physically satisfied with your sexuality? In your lifetime, you have engaged in only heterosexual activity? On average, how often do you have sexual intercourse? STRESS ASSESSMENT Please choose what you perceive is your stress level: Ideal Good Possible Problem PSA Check Extreme Y N DHEA SLEEP/MELATONIN Y N Thin and sparse pubic hair? Difficulty falling asleep? Fatty lower abdomen? Awaken at night and have difficulty returning to sleep? Ill-Being (non well-being)? Feel unrested upon waking in the morning? Lack of sexual Tendency to sleep fewer hours per night? attraction/interest? Frequent Illness/Depressed Other: Immune system? INCREASED TESTOSTERONE ESTROGEN CONVERSION Y N THYROID Y N Poor flexibility? Sensitive to cold, need extra blankets during winter? Decreased muscle strength? Cold hands or feet Excess fat on breasts? Lack of energy? Fat on belly? Depressed? Fat on hips and buttocks? Poor memory? Cellulite (thighs/buttocks)? Poor concentration? Varicose veins? Tendency to gain weight? Dry eyes? Constipation (slow, difficult digestion)? Loss of drive to succeed? Swollen hands or feet? Poor self image? Dry skin (face, elbows, legs)? Depression? Lack of perspiration during physical activity? Overly emotional? Finger nails (brittle/slow growing)? Poor memory? Slow hair growth? Poor concentration? AVCHHQ Copyright
3 CORTISOL Y N Shortness of breath? Allergic reactions, sneezing, runny nose, sore throat? Need 20 minutes to one hour daily for nap or quite time? Dizzy when standing up? Low blood pressure? Fast beating heart in stressful situations? Low resistance to stress? Feel better after eating something sweet? Crave salty or spicy foods? Digestive problems? Nausea? Underweight? Inflammatory arthritis? Intolerance to medications? Food allergies? Allergic symptoms present in nose, throat, ears and/or skin? Large brown age spots? Large white spots of de-pigmentation? Eczema? ESTROGEN (FEMALE ONLY) Y N Periods are irregular and painful? Periods have stopped (menopausal)? Lethargy, fatigue, memory loss? Vaginal dryness? Loss of Libido? Pain during intercourse? Excess body hair? Small breasts? Drooping, limp breasts? Bladder infections? Urinary incontinence? Hot flashes/night Sweats? Tension, irritability, anxiety? Headache? Joint pains, stiffness? Weight gain? Thinning hair? Aging wrinkled skin? GROWTH HORMONE Y N I have to struggle to finish jobs I feel a strong need to sleep during the day I often feel lonely even when I am with other people I have to read things several times before they sink in It is difficult for me to make friends It takes a lot of effort for me to do simple tasks I have difficulty controlling my emotions I often lose track of what I want to say I lack confidence I have to push myself to do things I often feel very tense I feel as if I let people down I find it hard to mix with people I feel worn out even when I ve not done anything There are times when I feel very low I avoid responsibility if possible I avoid mixing with people I don t know well I feel as if I am a burden to people I often forget what people have said to me I find it difficult to plan ahead I am easily irritated by other people I often feel too tired to do the things I ought to do I have to force myself to do all the things that need doing I often have to force myself to stay awake My memory lets me down PROGESTERONE/ESTROGEN Y N Often constipated with infrequent bowel movements? Stools are hard and compact? Strain during bowel movements? Diarrhea? Bad breath? Indigestion, bloating or gas after eating? Obesity? Yellow color to urine without the influence of B vitamins? Urine is cloudy and unclear? Dandruff? AVCHHQ Copyright
4 PERSONAL/FAMILY MEDICAL ASSESSMENT Heart Disease Stroke M= Me, S=Sister, B=Brother P=Parents, G=Grandparents Circle all that apply Asthma/Emphysema/COPD I feel unrested. SENSE OF WELL BEING Y N I need to generate excitement to avoid boredom. I wake up earlier and cannot sleep. Back Problems I have trouble getting to sleep. Cancer Things must be perfect. Chronic Fatigue Syndrome I must do it myself. Diabetes I must not fail. Migraines/Headaches Immune System Disorder Insomnia Kidney Disorders I cannot say no to new demands without feeling guilty. I am unable to relax I automatically express negative attitudes I am irritable, short-tempered, disappointed in the people around me Arthritis/Bursitis Lifestyles Assessment Y N TMJ Cigarettes/How Long? Viral &/or Bacterial Infections Pipe/How Long? Other: Cigars/How Long? YOUR EMOTIONAL STATE NONE SOMETIMES OFTEN Chewing Tobacco/How Long? Muscle aches and tension Overweight? Headaches or backaches Depression Poor memory Boredom Lack of motivation Sleep problems Nervous tics or habits Anger Frustration with self Frustration with others Lack of sense of humor Inability to make decision Average number of alcoholic drinks per week. The average number of business or social dinners eaten out per week: The number of caffeinated beverages/soda (coffee/tea/cola/) drank each day: The number of business lunches eaten each week: Number of overnight business trips per month: Job title or responsibility: Do you typically take work home? Y N JOB/WORKPLACE ASSESSMENT: Y N The consequences are severe if I make a mistake at work I frequently experience personal conflicts and/or harassment at work My job requires dealing with lots of red tape and frustration to get things done I can talk openly with management and my co-workers AVCHHQ Copyright
5 SKIN ASSESSMENT (Check all that apply) Acne Pigmentation variances Acne scars Rosacea Oiliness/Dryness Fine lines Wrinkles Large pore size Loss of glow/vitality Pale/sallow appearance Discoloration Loss of skin tone Brown Spots Sun Damage Broken Capillaries Spider Veins/Leg Veins Unwanted Hair/Whiskers Shaving Bumps Ingrown Hair JOB/WORKPLACE ASSESSMENT (Continued): Y N My company supports my efforts and rewards my contributions I feel I deserve more compensation I feel my job is at a dead end My company has reasonable policies for sick time, vacation, health and other benefits I am allowed a great deal of flexibility in my work schedule I experience a great deal of change and uncertainty in my job Other Job/Workplace Comments: Have you seen anyone, i.e., dermatologist, plastic surgeon, spa facility? Yes No If yes, please provide approximate date(s) of service. Please list any other comments or concerns: AVCHHQ Copyright
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