Men and Women's Health History
Please take your time filling out this questionnaire completely and honestly. You should commit at least one hour to complete this form. Information is acquired to evaluate your health profile from an integrative medicine perspective. However, it should also be the starting point for you to begin to see habits and exposures that prevent you from obtaining optimal health.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Sex
*
Female
Male
Nonbinary
Transgender
Other
Sexual Orientation
*
Heterosexual
Homosexual
Bisexual
Pansexual
Asexual
Social Security Number
*
For Insurance Purposes
Contact Information
Mobile Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
*
example@example.com
Address of the Primary Insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from above)
Street Address
Street Address
City
State
Zip Code
Name of Preferred Pharmacy
*
Pharmacy Zip Code
*
Pharmacy Phone Number
Please enter a valid phone number.
Primary Physician
PCP Phone Number
Please enter a valid phone number.
OB/GYN
OB/GYN Phone Number
Please enter a valid phone number.
Referred By:
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
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Insurance
Tula Wellness & Aesthetics is only in-network with select plans. Please call your insurance to verify if we are in-network.
Name of Primary Insured (if different than above)
*
First Name
Last Name
Relation to Insured
*
Social Security Number of Primary Insured
*
Date of Birth of Primary Insured
*
-
Month
-
Day
Year
Date
Name of Insurance Carrier
*
Member ID#
*
Group ID#
*
Address from the back of your insurance card
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Health History
What brings you to Tula Wellness? What concerns about your health do you have?
*
What are your health goals?
*
Please list the name and diagnosis date of any current medical conditions.
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Women's Health History
Date of last menstrual period
-
Month
-
Day
Year
Date
Menses (check all that apply)
Regular
Irregular
Painful PMS
Other
If you checked "other" above, please describe:
Number of Children
Childrens' Ages
Age at start of periods
Age at end of periods/menopause
History of abnormal pap smears?
Please Select
No
Yes
If Yes, please explain follow-up and treatment you received.
History of breast surgery?
Please Select
No
Yes
If Yes, please explain.
History of hysterectomy or pelvic surgery?
Please Select
No
Yes
If Yes, please explain.
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Men's Health History
Have you had any of the following procedures/exams? If yes, what was the date/result?
PSA?
Prostate Exam?
Vasectomy?
Cardiovascular Health:
Do you use Nitrates for chest pain?
No
Yes
Sexual Dysfunction
Do you have trouble starting or maintaining an erection?
Please Select
NO
YES
N/A
Do you experience pain with intercourse?
Please Select
NO
YES
N/A
Do you experience a low libido?
Please Select
NO
YES
Do you have difficulty achieving climax?
Please Select
NO
YES
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Hormone Therapy
Have you ever used hormone therapy?
Please Select
No
Yes
If yes, list medications, dose, directions and the duration of the treatment.
Did you have any problems? If yes, please explain.
Diagnostic Studies
Date of last mammogram:
-
Month
-
Day
Year
Date
Mammogram Results:
Please Select
Normal
Abnormal
Date of last pap smear:
-
Month
-
Day
Year
Date
Pap smear results:
Please Select
Normal
Abnormal
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Have you ever had additional diagnostic studies?
*
Yes (please provide information below)
No
Last Date Done & Results (-/+)
Please list a date and positive or negative (+/-) for any applicable diagnostic studies below.
Colonoscopy
Year
Result
-
+
Bone Density
Year
Result
-
+
Surgeries & Hospitalizations
Procedure & Date
Procedure & Date
Procedure & Date
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Allergies
Do you have an ALLERGY to a drug or other substance?
*
Please Select
No
Yes
If yes, please describe all.
Current Prescription Medications
Drug Name(s), Strength(s), Dosage(s). If none, please write NONE.
*
Supplements and Over-The-Counter
Drug Name(s), Strength(s), Dosage(s). If none, please write NONE.
*
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Family Health History
Please tell me about your family. Please include any family member with a history of tuberculosis, diabetes, cancer, emphysema, kidney disease, ulcer, nervous breakdown or gall bladder disease.
Mother:
Health Status
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Father:
Health Status
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Other Family Member(s):
Relationship:
Please Select
Brother
Sister
Son
Daughter
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Granddaughter
Grandson
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Health Status
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Please Select
Brother
Sister
Son
Daughter
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Granddaughter
Grandson
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Health Status
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Additional information related to your Family Medical History you would like me to know:
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Social and Socioeconomic History
Occupation:
Employer:
Highest Degree Earned:
Present Marital Status:
*
Please Select
Single
Partnered
Married
Divorced
Widowed
Spouse/Partner's Name:
Total # in household, including your children?
*
What are your main interests and hobbies?
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Habits & Lifestyle
Alcohol Use
*
Yes
No
If yes, what kind?
If yes, how many per week?
Tobacco Use
*
Yes
No
If yes, what kind?
If yes, how many per week?
Recreational Drug Use
*
Yes
No
If yes, what kind?
If yes, how many per week?
Have you ever felt that you ought to cut down on your drinking or drug use?
*
Please Select
No
Yes
Do you get annoyed at criticism of your drinking or drug use?
*
Please Select
No
Yes
Do you ever feel guilty about your drinking or drug use?
*
Please Select
No
Yes
Do you ever drink for an early morning "eye opener"?
*
Please Select
No
Yes
Do you feel safe in your surroundings?
*
Please Select
No
Yes
Do you have a history of sexual abuse?
*
Please Select
No
Yes
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Emotional Well Being
How well have things been going for you at school?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going with close friends?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for you with your children?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for you at your job?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for you with sex?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for you with your parents?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for you with your social life?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for your attitude
*
Please Select
Very Well
Fair
Poorly
Not Applicable
How well have things been going for you with your spouse/partner?
*
Please Select
Very Well
Fair
Poorly
Not Applicable
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Review of Systems
Please check any current symptoms you may have:
Constitutional
Recent Fever
Night Sweats
Hot Flashes
Unexplained Weight Loss/Gain
Decline in Libido
Cardiovascular
Chest Pains/Discomfort
Palpitations
Short of breath with Exertion
Respiratory
Cough/Wheeze
Coughing up Blood
Sexual Function
Pain with Intercourse
Vaginal Dryness
Decrease Sexual Desire
Inability to Orgasm
Other
Genitourinary
Painful/Bloody Urination
Leaking Urine
Nighttime Urination
Unusual Vaginal Bleeding
Frequent Urination
Skin
Rash
New or Change in Mole
Thin, Ridged, Splitting or Crumbling Nails
Psychiatric
Anxiety/Stress
Sleep Problems
Depression
Irritability
Eyes
Changes in Vision
Gastrointestinal
Heartburn/Reflux
Blood or Change in Bowel Movement
Nausea/Vomiting/Diarrhea/Constipation
Pain in Abdomen/Plevis
Irritable Bowel Syndrome/Digestive Problems
Fecal Incontinence
Blood/Lymphatic
Unexplained Lumps
Easy Bruising/Bleeding
Neurological
Headaches
Memory Loss
Fainting
Ear/Nose/Throat
Difficulty Health
Hay Fever/Allergies
Trouble Swallowing
Musculoskeletal
Muscle/Joint Pain
Recent Back Pain
Endocrine
Cold/Heat Intolerance
Increased Thirst/Appetite
Signature
Submit
Should be Empty: