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Transcription:

Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us? Occupation Marital Status Height Weight SURGICAL HISTORY List surgical procedures including plastic surgery. OTHER SERIOUS ILLNESS/OPERATIONS Date of last chest x-ray Date of last EKG MEDICATION Name Dosage Frequency

MEDICAL HISTORY Condition Self Family Clarification Heart disease disorder Gall bladder disease Headaches Uterine Cancer Osteoporosis High blood pressure Diabetes Asthma Liver Disease Ovarian Cancer Stroke Kidney disease Fibromyalgia Mental disorder Cervical Cancer Varicose veins Seizures Arthritis Thyroid disorder HIV/Aid Prostate Cancer Clotting Colitis Breast Cancer HORMONE AND VITAMIN SUPPLEMENTATION TAKEN Supplement Total daily dose Supplement Total daily dose Androstenedione Arimidex DHEA Estrace Estradiol Estriol Estrone Growth Hormone Human Growth Hormone Melatonin Pregnenolone Premarin

Progesterone Provera Tamoxifen Testosterone Thyroid Vitamin A Vitamin B3 Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Beta Carotene Calcium Co Q10 Chromium Digestive Enzyme Folic Acid Iron Magnesium Selenium Zinc Probiotic SOCIAL Yes No Amount Alcohol use Coffee Soft drink Tea High sugar food Chewing tobacco Cigarettes Excessive stress REVIEW OF SYSTEMS Head Headaches Blurred vision Cloudy vision Hair Hair loss Dry hair Clumps of hair coming out Cardiovascular Water retention Cannot tolerate much exercise Difficult breathing Chest pain while walking Heaviness in legs Calf muscle cramp often Heart pounds easily Palpitations

High blood pressure Low blood pressure Respiratory Shortness of breath Chronic lung congestion Wheezes Cough Acute congestion Gastrointestinal Constipation Diarrhea Heart burn Abdominal pain Certain foods cause ill feeling Blood in stool Epigastric pain Hernia Urinary Frequent Urination Burning with urination Incontinent issues Musculoskeletal Change in muscle mass Joint pain Limitation in motion Dermatological Dry skin Oily skin Acne Metabolic Difficulty gaining weight Difficulty losing weight Sensitivity to cold Wake up craving sweets Fatigue Feel faint Night sweats Increased thirst Craves sweets Weight loss more than 10 lbs in 6 months Weight gain more than 10 lbs in 6 months Psychological Rapid mood swings Moodiness/ change in mood Depression Lack of self-esteem Anxiety Difficulty concentrating Short attention span Forgetfulness Sleep Difficulty going to sleep Difficulty staying asleep Wake up frequently Hours of sleep per night:

FEMALES ONLY Bloating and swelling Breast tenderness Miscarriage Vaginal discharge Underactive sex drive Pelvic soreness Menstrual pain Insomnia Vaginal bumps/sores Premenstrual chest discomfort Hot flashes Night sweats Vaginal dryness Infertility Heavy menstrual bleeding Ovarian cysts Breast lump Irregular period Date of last menstrual cycle: Date of last pap smear/pelvic exam: Date of last mammogram: Sexually transmitted diseases: Form of birth control: MALES ONLY Pain with ejaculation Difficulty maintaining erection Sexual drive underactive Premature ejaculation Pain in genital area Infertility Low sperm count Discharge from penis Rash on penis Swelling in groin Loss of urine control Frequent urination at night Date of your last prostate exam: Do you use any medications for sexual dysfunction? Yes No If so, please list:

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