confidential health history form

Please provide your full name:

First NameLast Name
The following questions provide us with background information on your health and lifestyle to ensure the utmost of personalized care.
Please indicate the best email for secure electronic communication.
example@example.com
Please indicate the best Phone Number to reach you:

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Your Age (years)
Please rate your perceived baseline Health Status from poor (1 star) to high (5 stars)
What are your desired Goals/Outcomes of your consultation?
Health Concerns/Symptoms?
Please describe any new or priority health concerns, symptoms or problems
Ongoing Medical problems/illness or disease?
Please describe any chronic or ongoing health problems or diseases for which you may have required treatment or medical care.
Previous Surgical History
Please list all prescription medications currently used on a daily basis? ( name, dose, frequency)
Please list all prescription therapies with specific dose and frequency (one per line).
Medical Allergies:
Please list any medication allergies and indicate the type of reaction.
Food Sensitivities:
Please list any food sensitivities or intolerances
Lifestyle and Habits
Profession/Occupation
Please describe any professional designation/occupation or complete with N/A if not applicable.

Score your Stress from Low to High

	1	2	3	4	5

1 is Low, 5 is High

Do you practice meditation/stress reducing activities?

NoYes

Score your Mood on average most days from Low/Sad to High/Happy

	1	2	3	4	5

1 is Sad, 5 is Happy

Please describe your Dietary habits:

No special diet habitsAvoid red meatsMinimize fatMinimize CarbsVegetarianGluten free or avoidantAvoid dairy/cheeseDiet DrinksCandy/chocolate
Exercise habits

No regular exerciseModerate exerciseRegularly exercise (3 to 5 days per week)Daily exercise (6-7 days per week)
Exercise patterns: Indicate what type of exercise you engage in regularly

Aerobic exerciseStrength exercise/weightsFlexibility and Balance (yoga/pilates)
How many alcoholic beverages do you consume per week
Do you smoke cigarettes (if yes, how many packs per week?)
Do you use cannabis or psychedelic drugs (more than 1/week). Please describe:
Have you gained more than 15 lbs or 10% of your body weight in the past 5 years of since you were 30 years of age. If yes please indicate your baseline weight and weight gain.
Are you concerned about changes in your weight or body shape?
Do you have any concerns regarding facial aging such as; wrinkles, frown lines, skin laxity or jowls?
Women's Health History
Are your menstrual cycles:

RegularIrregularHeavyPainful
How long is your menstrual cycle (number of days between bleeding)
How long is your menstruation (how many days do you bleed?)
Date of Last Menstrual Cycle (first day of last period)

MonthDayYear
Date
How old were you at your menarche (age of first period?)
Past Medical History
Please describe any medical conditions or health problems you currently or previously had:
Do you have any blood borne communicable diseases? (EX. HIV/AIDS/Hepatitis)
Headaches or Migraines
Mood Disorder or Anxiety
Allergies or Asthma
Respiratory Disease
Heart Disease or prior Heart Attack
Diabetes
Osteoporosis
Gastrointestinal Disease
Cancer (list specific diagnosis)
Liver Disease
Kidney Disease

Please List Any Family History

	Maternal	Paternal
Breast Cancer
Cancer (other)
Heart Disease
Diabetes
Osteoporosis
Dementia

Lifestyle and Habits

Women's Health History

Past Medical History

Appointment Scheduling