PRIMARY PHYSICIAN INFORMATION
Does an immediate family member currently have or ever had any of the following?
Cardiovascular disease (heart attack, stroke, coronary artery bypass)
Diabetes, thyroid or other Endocrine Disorder
If yes for other illnesses, please list them here
Do you smoke or use tobacco products?
If yes, on average, how much do you smoke or use tobacco per day?
How many years have you used tobacco?
If yes, on average, how much do you drink per day or week?
How many years have you been drinking?
Do you take over the counter supplements?
If Yes, list Name and Quantity per day/week.
Do you exercise regularly?
If Yes, please describe.
Can you describe your diet? Please describe the foods you eat on a regular basis. Have you been following any certain diet guidelines such as the mediteranean diet, vegetarian, plant based diet, low carb, keto diet, orthe standard american diet (SAD) ?
Any known deficiency including minerals and electrolytes
Orthopedic or muscle disorder including fracture or joint disorders
Use of medications (if , list medications below)
Auto-immune system disorder
Heart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack
Frequent upper respiratory infections
Edema / excess fluid retention
Emotional disorders / depression
Genital – Urinary disorder
Hypertension (High blood pressure)
Thyroid, Diabetes or other endocrine disorder including insulin resistance
Heart attack (myocardial infarction)
Use the space below to explain the history of any above checked problems. Also please add any other health issues you might have that we didn’t ask about
List all the medications you are taking.
Please be specific (Name, dosage, etc.) or specify “none”:
Do you have any allergies to medications or foods? If yes, please list the substance and the reaction below:
Prior history of steroids or other hormones?
If yes, list type of medication, strength, dosage used, and dates of use (month and year) to your best memory
Do you currently have or have experienced any of the following symptoms?
If Yes, please check and explain below:
Increasing fat deposits around the abdomen and/or thighs
Progressive osteoporosis,decreasing bone density, or low trauma fractures
Loss of concentration,sociability, activity
Decreased desire and ability to exercise
Decreased energy or endurance
Sore Muscles, joint pain(s) or swelling
Sagging, loose or thin skin
Decreasing size of testicles
Decreasing muscle strength
Weight loss – Unexplained
Please use this space to explain any additional information