Name
First Name
Last Name
Person Filling Out This Form (if not the Patient)
First Name
Last Name
Relationship to the Patient
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
City/State or Town/Country if not in the US
Gender
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Did something trigger your change in health?
Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Are you experiencing any of the following symptoms?
cough >3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
Vaccinations
Did you receive your childhood vaccinations?
Yes
No
Unknown
Yes
No
Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
Allergies
Do you have any allergies?
Yes
No
If yes, please list.
Do you have any drug allergies?
Yes
No
If yes, please list.
Sexual Health
What is your sexuality?
Heterosexual
Gay
Bisexual
N/A
Other
Have you had the tests below?
Yes
No
Unsure
PSA
Cardiac Stress Test
HIV Test
Hepatitis C Test
Colonoscopy
Testosterone Level
Have you ever been diagnosed with or tested positive for a sexually transmitted disease?
Yes
No
If yes, please check all that apply
Not Satisfied
Somewhat Satisfied
Satisfied
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis
Medical History
To your knowledge, have any of your blood relatives had any of the following section?
None
Unknown
Yes
Family History
Mother
Father
Sibling
Children
Mat. Grandparent
Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Surgical History
Yes
No
Appendix Removal
Vasectomy
Pituitary Surgery
Orchiectomy
Prostate Biopsy
Gastroenterology Related Medical History
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Cardiology Related Medical History
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Endocrine Related Medical History
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Infertility
Weight gain
Weight loss
Eating disorder
Other
Nephrology Related Medical History cont.
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
Orthopedics Related Medical History cont.
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Immune System Related Medical History cont.
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
Lung Related Medical History
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Cancer History
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Cancer History Cont.
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Prostate cancer
Skin cancer
Other
Medical Health
Mental Health Condition History
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Please list any significant physical trauma you've experienced
Please list emotional trauma you've experienced in your life
Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Other
Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Medication history
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Anabolic Steroids
Medications
Supplements
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