Judith Crabtree, WH-NP
Today's Date:
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Name
Date of Birth
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Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Occupation
Marital Status
Race/Ethnicity:
Sexual Orientation:
Heterosexual
Homosexual
Bisexual
Name of Primary Care Provider:
Referred By:
Reason for today's visit:
General Medical History
1) Have you have a prostate exam?
Yes
No
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Result
Normal
Abnormal
2) Have you had a PSA for prostate screening?
Yes
No
Date
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Result
Normal
Abnormal
3) Have you had a colonoscopy?
Yes
No
Date
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Day
Year
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Result
Normal
Abnormal
4) List any occupational or other toxins that you may have been exposed to:
5) Allergies:
None
List Allergies:
6) Surgeries:
None
List Surgeries:
7) Hospitalizations (last 5 years):
None
List Hospitalizations:
7) Medical Problems:
None
List Medical Problems:
8) Current Medications and Supplements List Dose:
None
See Attached
List Medications:
9) Current Complementary or Alternative Therapy
None
List:
10) Weekly Exercise Routine
None
List:
Do you currently smoke Cigarettes?
Yes
No
# Years:
Use Recreational Drug Use?
Yes
No
Alcohol Use?
Yes
No
Drinks per week:
Caffeinated Beverages:
Yes
No
Cups per day:
Preferred Pharmacy:
Do you vape nicotine or other substances?
Yes
No
Back
Next
Hormonal/ Endocrine History
1) Do you have a decrease in libido (Desire)?
Yes
No
2) Do you have a lack of energy?
Yes
No
3) Do you have a decrease in strength and/or endurance?
Yes
No
4) Are you sad and/ or grumpy?
Yes
No
5) Are you erections less strong?
Yes
No
6) Are you falling asleep after dinner?
Yes
No
7) Have you noticed deterioration in your work performance?
Yes
No
8) Have you recently experienced unexplained weight gain?
Yes
No
How much?
9) Have you lost height?
Yes
No
10) What is your waist size?
Has it changed?
Yes
No
11) Have you noticed an onset/ worsening of acne?
Yes
No
12. Have you ever been touched in a way that makes you feel uncomfortable?
Yes
No
If yes would you like to discuss?
13. Have you ever controlled binge eating with vomiting or used a laxative to prevent weight gain?
Yes
No
14) Have you noticed an onset/ worsening of hair loss?
Yes
No
15) Do you have skin tags or discoloration on your neck, underarms or thighs?
Yes
No
16) Are you being treated for high blood pressure?
Yes
No
17) Have you been advised to lower your blood pressure?
Yes
No
18) Do you have high cholesterol or high triglycerides?
Yes
No
If so select
High cholesterol
High triglycerides?
19) Do you snore or have sleep apnea?
Yes
No
20)Has anyone ever Observed you holding your breath during sleep?
Yes
No
21) Do you often wake up at night to urinate?
Yes
No
Please explain in detail any questions that you have answered yes to above:
Family History
If living(L) please indicate state of health, if deceased(D) please indicate cause of death:
Rows
Age
Living
Deceased
State of health/ cause of death
Father
Mother
Brothers
Sisters
Have any of your Immediate family or Grandparents had the following?
Rows
Yes
No
Relation
Cancer:
a) Colon
b) Prostate
c) Uterine or Ovarian
d) Breast
Alzheimer's
Diabetes
Heart Disease
High Blood Pressure
Kidney Heart Disease
Osteoporosis
Thyroid Disease
Stroke
Auto Immune Disorder
Please list any special concerns you would like to discuss:
Patient Signature
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