6. MEDICAL HISTORY INTAKE FORM

MEDICAL HISTORY INTAKE FORM
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do we have your permission to contact you?
If yes, your preferred methods of communication. (Check all apply)
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?

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

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

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

Rows	NAME OF MEDICATION	REACTION	SERVERITY
1.
2.
3.

5. ARE YOU ALLERGIC TO ANY FOOD?

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

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

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

Rows	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)?

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

IF YES, PLESE LIST DATES & REASON FOR HOSPITALIZATION

Rows	REASONS FOR HOSPITALIZATION	DATE
1.
2.
3.

10. HAVE YOU EVER HAD ANY SURGERIES OR OPERATIONS?

IF YES, PLESE LIST TYPE OF SURGERY AND DATES (INCLUDING TONSILS, DENTAL SURGERY, APPENDIX, AND OTHERS)? IF NONE, WRITE N/A.

Rows	TYPE OF SURGERY	DATE
1.
2.
3.

11. HAVE YOU EVER HAD ANY INJURY?

12. IF YES, PLESE LIST INJURIES AND DATES (SUCH AS AUTOMOBILE ACCIDENT, SERIOUS FALLS, SPORTS INJURIES, BROKEN BONES, GETTING KNOCKED UNCONSCIOUS, OTHERS)? IF NONE, WRITE N/A.

Rows	TYPE OF INJURY	DATE
1.
2.
3.

13. HAVE YOU HAD ANY LABORATORY TESTS DONE IN THE PAST FIVE YEARS?
If Yes, Please List All Testing Done And Results.
Lab Results Upload

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14. PREVIOUS GENITO-URINARY TRACT HISTORY:

FEMALES ONLY - IF NOT APPLICABLE PLEASE WRITE/SELECT NONE OR N/A
First Day of Last Menstrual Period?

Date (DD/MM/YYYY)
Age of First Period?

Age
Duration of Period?

How Many Days
Menopause Age/Year Began?

Age/Year Began (YYYY)
Any Post-Menopause Bleeding?
Current Method of Birth Control
Any Problem with Current Method??
Previously used methods:

Other
Number of Pregnancies?

Number
Full Term Deliveries?

Number
Pre-Mature Deliveries?

Number
Number of Living Children?

Number
Number of Miscarriages?

Number
Number of Abortion?

Number
15. Last Breast Examination by A Physician?

Yes. When? (MM/YYYY)
Were The Results Normal?
16. Last Mammography?

Yes. When? (MM/YYYY)
Were The Results Normal?
17. Last Pelvic Exam Exination by A Physician?

Yes. When? (MM/YYYY)
Were The Results Normal?
18. Last PAPinicolao Smear?

Yes. When? (MM/YYYY)
Were The Results Normal?
19. Last CA 125 Ovarian Cancer Screen (Blood Test)?

Yes. When? (MM/YYYY)
Were The Results Normal?
20. PREVIOUS GENITO-URINARY TRACT HISTORY:

MALES ONLY - IF NOT APPLICABLE SELECT NONE OR N/A
Last DRE (Digital Rectal Examination, Prostate Examination)?

Yes. When? (MM/YYYY)
Were The Results Normal?
Last Testicular or Prostate Ultrasound

Yes. When? (MM/YYYY)
Were The Results Normal?
Last PSA (Prostate Specific Antigen)

Yes. When? (MM/YYYY)
Were The Results Normal?
FAMILY HISTORY

IF NOT APPLICABLE PLEASE WRITE/SELECT NONE OR N/A
21. Is Your Mother Living?

Yes. 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?

Yes. Please List:
22. Is Your Father Living?

Yes. 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?

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

No. 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?

No. Please List Health Problems:
Numbers of Deceased Sisters
Please list age at death and cause of death
25. Do You Smoke?

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

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

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

Yes. 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?

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

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

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

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

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

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

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

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

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

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

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

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

Yes. 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.
Signature
TODAY'S Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

MEDICAL HISTORY INTAKE FORM

14. PREVIOUS GENITO-URINARY TRACT HISTORY:

20. PREVIOUS GENITO-URINARY TRACT HISTORY:

FAMILY HISTORY

REVIEW OF BODY SYSTEMS