New Patient Medical Questionaire

New Patient Medical Questionaire
General Patient Information
Client Name

First NameLast Name
Client E-Mail
example@example.com
Phone Number
Format: (000) 000-0000.
Client Gender
Client Birth Date

MonthDayYear
Client Height (feet, inches)
Client Weight (lb's)
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Client and Family Medical History

Please check all that apply
Do you currently take any prescription medications?
Please list your Current Medications (including dosage & frequency):
Please list you PAST used medications, supplements (including dosage & frequency):
Have you ever had (Please check all that apply)
Any family history of the above? If yes, please explain:
Write n/a if this does not apply
Have you had any surgeries? Please list all surgeries and dates.
Write n/a if this does not apply
Any other medical problems/concerns not already identified?
Write n/a if this does not apply
Are you experiencing any of the following symptoms? (check all that apply)
Any other medical problems/concerns not already identified?
Write n/a if this does not apply
Lifestyle Section
Occupational activity level:
Alcohol Consumption
Caffiene Consumption
Do you smoke?
Exercise
Are you currently following a structured exercise plan? If yes, please explain.
How many days per week do you strength train?
Do you train at home or in a gym?
What exercises interest you?

Other
What are your eating habits?
Include other comments regarding your Medical History
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Medical Records or Previous Treatment History

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New Patient Medical Questionaire

General Patient Information

Client and Family Medical History

Lifestyle Section