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Afghanistan
Albania
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Cameroon
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Cape Verde
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Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
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Cote d'Ivoire
Croatia
Cuba
Curaçao
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Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
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Guadeloupe
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Guatemala
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Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kiribati
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Kosovo
Kuwait
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Laos
Latvia
Lebanon
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
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Romania
Russia
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South Sudan
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eSwatini
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Health Goals and Status
What are your health, wellness and fitness goals with this visit?
How would you rate your current health status?
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Approximately, when was your last visit with a doctor for a check-up or illness?
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Height (inches)
Current Weight (lbs)
Max Weight (lbs)
Has anything triggered a change in your health?
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No
Describe what happened
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Medication History
Please list any medications you take
Please list any supplements you take
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Allergy History
Please list any MEDICATION allergies, intolerances, or adverse reactions you have had
Please list any SUPPLEMENT allergies, intolerances, or adverse reactions you have had
Please list any FOOD allergies, intolerances, or adverse reactions you have had
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Hospitalizations, Surgeries, and Trauma
Please list any hospitalizations
Please list any surgeries (including cosmetic)
Please list any trauma (car accidents, head injuries, back injuries, broken bones)
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Past Medical History
Please any DIAGNOSES you have received in the past
Gastrointestinal
Irritable Bowel Syndrome
Crohn's Disease
Ulcerative Colitis
Gastric or Peptic Ulcer
GERD (reflux)
Other
Describe GI Condition
Cardiovascular
Heart Attack
Other Heart Disease
Stroke
Arrythmia (irregular heart beat)
High Blood Pressure
Blood Clot
Other
Describe CV Condition
Metabolic / Endocrine
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic Syndrome / Insulin Resistance / Pre-diabetes
Low Thyroid / Hypothyroidism
Overactive Thyroid / Hyperthyroidism
High Cholesterol
High Triglycerides
Endocrine Problems
Infertility
Adrenal Fatigue
Polycystic Ovary Syndrome
Other
Describe Endocrine Condition
Cancer
Prostate Cancer
Ovarian Cancer
Other Cancer
Describe Cancer Diagnosis and Status
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Past Medical History
Please any DIAGNOSES you have received in the past
Genital / Urinary System
Kidney Stones
Gout
Erectile Dysfunction
Frequent UTI
Prostate infection
Interstitial Cystitis
Frequent Yeast Infections
Other sexual dysfunction
Other
Describe GU Problem
Inflammatory / Autoimmmune
Chronic Fatigue Syndrome
Rheumatoid Arhritis
Autoimmune disease
Poor immune function (frequent infections)
Food Allergies
Environmental Allergies
Other
Describe your inflammatory issues
Respiratory
Asthma
Sleep Apnea
Chronic Sinus infections
Bronchitis
Other
Describe your respiratory issues
Musculoskeletal / Pain
Osteoarthritis
Fibromyalgia
Chronic Pain
Joint Problems or Limitations
Other
Describe your pain or movement issues
Neurologic / Behavioral
Bulimia
Anorexia
Binge Eating Disorder
Night Eating Syndrome
Other
Describe Neurological or Behavioral Diagnoses
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Symptom Review
Check ALL symptoms you have experienced in the LAST 6 MONTHS
General
Decrease in muscle strength
Decrease in Lean Body Mass
Decreased bone mineral density
Increased body fat, especially midsection / visceral fat
Lower sex drive
Decreased sexual function or erectile problems
Decreased or absent morning erection
Decreased Energy
Depressed Mood
Decreased Motivation and Drive
Decreased Concentration and Focus
Head, Eyes, Ears
Distorted sense of smell
Distorted taste
Visual changes
Heaing problems
Headache
Please provide more detail about your vision changes
Please provide more detail about your headaches
Musculoskeletal
Muscle spasm
Joint pain
Tendonitis
Limitations in mobility or range of motion
Describe limitations
Lymph Nodes
Enlarged lymph nodes
Tender lymph nodes
Which lymph nodes are enlarged or tender?
Digestion
Heartburn
Constipation
Cramps
Diarrhea
Skin Problems
Hair loss
Acne
Dry or Scaly Skin
Hives
Rash
Respiratory
Cough
Snoring
Wheezing
Cardiovascular
Angina / Chest Pain
Breathlessness
Irregular pulse
Palpitations
Swollen ankles / feet
Urinary
Trouble with starting urine stream
Leaking / incontinence
Frequent urination / nighttime urination
Urgency
Pain or burning with urination
Prostate infection
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Family and Genetic History
Check any conditions that apply
Mother
Father
Sibling
Grandparents
Children
Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Asthma
Dementia
Other
Please provide details that may be pertinent
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Health Screening Exam History
Screening Exams
Type a question
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Men's Health
Have you ever had a PSA test?
Yes
No
Year of last PSA test
PSA Level
0-2
2-4
4-10
>10
Check all that apply
Prostate enlargement
Urgency, hesitancy, change in urine stream
Difficulty attaining or maintaining erections
Sex drive: Overactive
Sex drive: Underactive
Lack of morning erections
Nocturia (urination at night)
Lump or mass in scrotum
History of infertility or low sperm count
Use of Viagra, Levitra, Cialis or other medication for sexual function
Use of Testosterone
Use of HCG
Use of HGH
Use of DHEA
Women's Health
Are you still menstruating?
Yes
No
Date of LMP?
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Day
Year
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Periods are:
Regular
Irregular
Periods are:
Light
Medium
Heavy
Change in Periods?
Yes
No
Birth Control
Yes
No
Obstetric History
Are you experiencing any of these symptoms: (Check all that apply)
Hot flashes
Night sweats
Mood swings
Underactive sex drive
Vaginal dryness
Vaginal itching
Pain with intercourse
Incontinence / Leaking
Breast tenderness
Ovarian cyst
PMS
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Nutrition
Do you currently follow a diet or nutrition program?
Yes
No
What diets have you tried? (check all that apply)
Low fat
Low carbohydrate
High Protein
No wheat / gluten
Low sodium
Diabetic
Atkins / South Beach
Dairy Free
Detoxification diet
Vegetarian
Vegan
Other
Describe diet
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Fitness / Exercise
Cardiovascular Exercise
Resistance Training
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Social History
Tobacco Use
How many drinks per week? (5 ounces wine, 12 ounces beer, 1.5 ounces liquor)
None
Rarely
1-3
4-6
7-10
10-15
>15
Recreational Drug Use?
Never
Occasionally
Frequently
Quit
Which drugs?
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Relationship History
Marital / Relationship Status
Single
Married
Divorced
Long term partnership
Widowed
Children
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Are there any other thoughts or comments you would like to share about your health or goals that you would like to share?
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