6. MEDICAL HISTORY INTAKE FORM

MEDICAL HISTORY INTAKE FORM
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Mobile Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do we have your permission to contact you?*

YesNo
If yes, your preferred methods of communication. (Check all apply)*

Mobile PhoneLeave a Voice MessageText MessageEmail
Your Height?*
in inches
Your Current Weight?*
in lbs
Your Goal Weight?*
in lbs
1. Your Expectation From The Program?*
2. Please Upload a Valid US Government ID (Driver's License, State ID or Passport)*

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3. WHAT MEDICAL CONDITIONS(S) ARE YOU CURRENTLY DIAGNOSED WITH? FOR HOW LONG?*

	NAME OF MEDICAL CONDITION	HOW MANY YEAR	HOW MANY MONTHS
1.
2.
3.

Others please list below
4. ARE YOU ALLERGIC TO ANY MEDICATION?*

NoYes

IF YES, PLESE LIST THE MEDICATION AND THE REACTION YOU HAVE?*

	NAME OF MEDICATION	REACTION	SERVERITY
1.
2.
3.

5. ARE YOU ALLERGIC TO ANY FOOD?*

NoYes, Please List Them And The Reaction You Have.
6. ARE YOU ALLERGIC TO ANYTHING ELSE? POLLEN, CATS, WEEDS, ETC?*

NoYes, Please List Them And The Reaction You Have.
7. ARE YOU CURRENTLY TAKING ANY MEDICATIONS?*

NoYes

IF YES, PLESE LIST THE MEDICATION, DOSAGES & HOW LONG HAVE YOU BEEN TAKING IT?*

	NAME OF MEDICATION	DOSAGE	SINCE (DATE)
1.
2.
3.

Others Please List Them.
8. DO YOU TAKE ANY SUPPLEMENTS (such as vitamins, minerals, herbs, over-the-counter medication, other)?*

NoIf Yes, Please List Them Below.
9. HAVE YOU EVER HAD TO BE HOSPITALIZED?*

NoYes

IF YES, PLESE LIST DATES & REASON FOR HOSPITALIZATION*

	REASONS FOR HOSPITALIZATION	DATE
1.
2.
3.

10. HAVE YOU EVER HAD ANY SURGERIES OR OPERATIONS?*

NoYes

IF YES, PLESE LIST TYPE OF SURGERY AND DATES (INCLUDING TONSILS, DENTAL SURGERY, APPENDIX, AND OTHERS)?*

	TYPE OF SURGERY	DATE
1.
2.
3.

11. HAVE YOU EVER HAD ANY INJURY?*

NoYes

12. IF YES, PLESE LIST INJURIES AND DATES (SUCH AS AUTOMOBILE ACCIDENT, SERIOUS FALLS, SPORTS INJURIES, BROKEN BONES, GETTING KNOCKED UNCONSCIOUS, OTHERS)?*

	TYPE OF INJURY	DATE
1.
2.
3.

13. HAVE YOU HAD ANY LABORATORY TESTS DONE IN THE PAST FIVE YEARS?*

NoYes
If Yes, Please List All Testing Done And Results.
Lab Results Upload

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14. PREVIOUS GENITO-URINARY TRACT HISTORY:

FEMALES ONLY
First Day of Last Menstrual Period?*

N/ADate (DD/MM/YYYY)
Age of First Period?*

N/AAge
Duration of Period?*

N/AHow Many Days
Menopause Age/Year Began?*

N/AAge/Year Began (YYYY)
Any Post-Menopause Bleeding?

YesNo
Current Method of Birth Control*
Any Problem with Current Method??

YesNo
Previously used methods:

Birth Control PillCondomsDiaphragmDepo ProveraIUDNova RingNo Previous Birth ControlOther
Number of Pregnancies?*

N/ANumber
Full Term Deliveries?*

N/ANumber
Pre-Mature Deliveries?*

N/ANumber
Number of Living Children?*

N/ANumber
Number of Miscarriages?*

N/ANumber
Number of Abortion?*

N/ANumber
15. Last Breast Examination by A Physician?*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
16. Last Mammography?*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
17. Last Pelvic Exam Exination by A Physician?*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
18. Last PAPinicolao Smear?*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
19. Last CA 125 Ovarian Cancer Screen (Blood Test)?*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
20. PREVIOUS GENITO-URINARY TRACT HISTORY:

MALES ONLY
Last DRE (Digital Rectal Examination, Prostate Examination)?*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
Last Testicular or Prostate Ultrasound*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
Last PSA (Prostate Specific Antigen)*

NoneYes. When? (MM/YYYY)
Were The Results Normal?*

YesNoN/A
FAMILY HISTORY
21. Is Your Mother Living?*

NoYes. What is Your Mother's Age?
If No, please list her age of death and cause of death.
Does your mother have any health problems such as HEART DISEASE, CANCER, or other?

NoYes. Please List:
22. Is Your Father Living?*

NoYes. What is Your Mother's Age?
If No, please list her age of death and cause of death.
Does your father have any health problems such as HEART DISEASE, CANCER, or other?

NoYes. Please List:
23. Numbers of Living Brothers*
Are They Healthy?

YesN/ANo. Please List Health Problems:
Numbers of Deceased Brothers*
Please list age at death and cause of death
24. Numbers of Living Sisters*
Are They Healthy?

YesN/ANo. Please List Health Problems:
Numbers of Deceased Sisters*
Please list age at death and cause of death
25. Do You Smoke?*

NoYes. How Many Per Day?
26. Do You Drink Alcohol Beverages??*

NoYes. How Many Per Week?
27. Do You Use Illicit Drugs?*

NoYes. Please List:
28. Are You on a Special Diet?*

NoYes. Please List Details:
REVIEW OF BODY SYSTEMS
28. HEAD, EAR, EYES, NOSE, THROAT. Any problems with loss of hearing, sense if taste, sense of smell or vision?*

NoYes. Please List Details:
29. CARDIOVASCULAR. Any problems with chest pain, shortness of breath, asthma, high blood pressure, other?*

NoYes. Please List Details:
30. GASTROINTESTINAL. Any problems with blood in the urine, pain or burning when urinating, exposure to sexually transmitted disease, or other?*

NoYes. Please List Details:
31. MUSCULOSKELETAL. Any problems with joints, ligaments, muscles, bones, serious injuries, other?*

NoYes. Please List Details:
32. NEUROPSYCHIATRIC. Have you ever attempted suicide or do you have thoughts of suicide?*

NoYes. Please List Details:
33. Have You Ever Used Tranquilizer or Antidepressants?*

NoYes. Please List Details:
34. Have You Ever Been Knocked Unconscious or Had a Spinal Injury?*

NoYes. Please List Details:
35. Have You Had Any Other Problems With Your Nervous System or Have You Had Any Other Psychiatric Problems?*

NoYes. Please List Details:
36. ENDOCRINE. Have you ever had problems with blood sugar, thyroid gland, other glandular problems?*

NoYes. Please List Details:
37. Have You Lost or Gained Weight in The Past Year, And If So, How Much?*

NoYes. Please List Details:
38. SKIN. Have you ever had skin cancer, moles, warts or lesions removed, or other skin problems?*

NoYes. Please List Details:
39. BLOOD & LYMPHATICS. Have you ever had any circulatory problems or problems with your lymphatic system?*

NoYes. Please List Details:
40. Do You Have ANY Other Problems Not Mentioned Above?*

NoYes. Please List Details:
Our ability to draw effective conclusions about the present state of your health & how to improve will depend onyour ability to respond thoroughly and accurately. Other written questionnaires & questions will be posed by the physicians, providers & staff during your consultations. Your team at Anti-Aging & Weight loss Center will be the only people to review these forms with your consent. Your confidentiality will be strictly maintained. Your careful consideration of each of the following questions will enhance our efficiency in treating you.
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MEDICAL HISTORY INTAKE FORM

14. PREVIOUS GENITO-URINARY TRACT HISTORY:

20. PREVIOUS GENITO-URINARY TRACT HISTORY:

FAMILY HISTORY

REVIEW OF BODY SYSTEMS