Adult Physical Exam Form
Botumzup Health and Wellness, LLC
Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Current Medication List
Medication Name
Mg/Dosage
Reason
1
2
3
4
5
Past Medication List
Medication Name
Mg/Dosage
Date(from)
Date(to)
Reason
1
2
3
4
5
Do you have an operation of a surgery experience?
*
Yes
No
If yes, please list them all.
Mark if you have any of these conditions currently or in the past.
*
Weight loss
Fatigue
Memory Loss
Headache
Visual Loss
Decreased Hearing
Sinus Pain
Hoarseness
Sore Throat
Trouble Swallowing
Breast Mass
Breast Pain
Skin Changes
Anemia
Chest Pain
Irregular Heart Beat
Elevated Blood Pressure
Heart Disease
Shortness of Breath
Swelling of Limbs
Diabetes
Excessive Thirst
Excessive Urination
Bloody Stool
Constipation
Diarrhea
Heart Burn
Jaundice
Kidney Stones
Nausea Vomiting
Libido Change
Stroke
Anxiety
Depression
Sleep Issues
Other
Do you smoke?
Yes
No
Do you have any Drug or Food Allergies?
*
Yes
No
If yes, please list them all.
How much coffee, tea, or carbonated beverage do you drink daily?
How many beers, mixed drinks, or glasses of wine do you have weekly?
Family History
Mother
Father
Brother/sister
Grandfather
Grandmother
Other Relatives
Alcoholism
Allergies
Diabetes
Tuberculosis
Heart Disease
Stroke
High Blood Pressure
Depression / Anxiety / Bipolar
Cancer
High Cholesterol
Thyroid issues
Additional Notes
Submit
Should be Empty: