Name* First Middle Last Date* Sex*Email* Phone*Birthdate* Height*Weight*Amount Over or Under Weight*Blood PressurePulseDo you wish to consult: (Check one)*For a check-upFor a particular concernFor a particular concern with comprehensive appointment and health programDo you feel that you are basically healthy?*What are your primary health concerns?*FAMILY HEALTH HISTORYFather's age if livingMother's age if livingFather's state of HealthMother's state of HealthFather's age at deathMother's age at deathCause of death or poor health concernsCause of death or poor health concernsPlease list any other brothers, sisters and/or children with current age, age of death, current health status and any health concerns or cause of death if applicable.Check Disease(s) Known To Have Occurred in the Family* Diabetes Tuberculosis Allergy Ulcers Heart Disease Liver Diseases Asthma Migraines High Blood Pressure Kidney Disease Cancer Arthritis Convulsions Lung Problems Other None About Yourself Present occupation*Previous occupation*When:*Check one:*SingleMarriedWidow(ed)DivorcedLive with:*FamilyAloneRoommateSignificant OtherDo you smoke tobacco?*Amount?How long?If stopped, how long since you quit?Do you use caffeine?*Amount?How long?If stopped, how long since you quit?Do you use recreational drugs?*If yes, which?How often?If stopped, how long since you quit?Do you ever use fake sweeteners?*If yes, how often?Do you drink alcohol?*If yes, how often and how many drinks?Do you take any vitamins and/or supplements?*If yes, please list allPAST HISTORY Fever, chills, night sweats*YesNoBlood in bowel movements*YesNoSevere or frequent headaches*YesNoDiarrhea*YesNoPeriods of unconsciousness*YesNoConstipation*YesNoComplete or partial blindness*YesNoAlternating diarrhea and constipation*YesNoFrequent dizzy spells*YesNoHearing trouble*YesNoFrequent indigestion or gas*YesNoEye trouble*YesNoUlcer of stomach*YesNoDo you feel anxious, depressed, or irritable?*YesNoBlood in urine*YesNoTrouble dealing with stress*YesNoNeed to urinate frequently*YesNoHay fever or sinus trouble*YesNoUrinate during the night*YesNoGoiter or thyroid trouble*YesNoKidney or bladder stones*YesNoAsthma*YesNoProtein or albumin in urine*YesNoCough*YesNoTrouble starting urine stream*YesNoMucous in chest or bronchial area*YesNoVenereal disease or Herpes*YesNoShortness of breath*YesNoDiabetes or sugar in urine*YesNoCoughed up blood*YesNoHypoglycemia*YesNoHigh blood pressure*YesNoArthritis, Bursitis, Rheumatism*YesNoHave you ever had jaundice hepatitis, or mono?*YesNoSkin rashes*YesNoDo you awaken at night out of breath?*YesNoIs your appetite good?*YesNoFast, irregular, or slow pulse*YesNoDo you exercise at least three times/week?*YesNoPain in chest?*YesNoDo you sleep well?*YesNoAllergiesYesNoDo you feel rested in the morning*YesNoFrequent colds or flu*YesNoDo you feel tired after eating?*YesNoVomit blood*YesNoTired or diminished energy during the day?*YesNoBlack bowel movements*YesNoSwollen lymph glands?*YesNoPlease explain any “yes” answers above (when, how often, severity)Serious illnesses as a child: (Check appropriate one(s)) Rheumatic Fever Kidney Trouble Prolonged Fever Heart Trouble Other Serious illnesses as an adult:Allergies:Medications:Operations/Injuries:When?Have you ever been in the hospital for other reasons? (Please indicate when & why)Has your weight changed in the past year?YesNoIf yes, how much?Current weight:Weight 1 year ago: (approx.)Weight 5 years ago: (approx.)How much water do you drink in a day?What types of sweets, sodas and other sugars do you consume regularly?What do you typically eat for breakfast on the weekdays?What do you typically eat for breakfast on the weekends?What do you typically eat for lunch on the weekdays?What do you typically eat for lunch on the weekends?What do you typically eat for dinner on the weekdays?What do you typically eat for dinner on the weekends?How much sleep do you typically get a night?Please describe your sleeping patterns/habits:How many bowel movements do you have in a day? (if less than 1, how many in a week?)Please describe your exercise routine.FOR WOMENNumber of pregnancies:Miscarriages:Abortions:Number of living children:Ages:Age when menstrual periods began:Ended:How frequent are periods?How long:Excessive flow?YesNoSpotting between periods?YesNoPain/cramps during period?YesNoBlood clots during periods?YesNoIf yes, colorSharp pain in ovaries?YesNoIf yes, which side?Lumps inBreastArmpitGroin areaHysterectomy?YesNoIf yes, when?Have you taken birth control pills?YesNoFor how long?If you have since stopped taking birth control pills, when did you stop?Have you worn an IUD?YesNoIf yes, for how long?If you no longer wear an IUD, when did you stop?FOR MENLumps in groin area or just above and to the side of the penisYesNoHas the quality of your orgasm, or force of release, diminished?YesNoTroubles concerning erection or ejaculation?YesNoProstatitis?YesNoFOR ALL CLIENTSPlease use this space to write in any other important health considerations you may have. The more specific, yet descriptive, your information is, the more we will be able to help you.