Medical History Form

Personal Information

ADDRESS

PHONE NUMBER

OTHERS

Medical History

GENERAL

Gender

PRIMARY PHYSICIAN INFORMATION

OTHERS

FAMILY HISTORY

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

Hypertension

High cholesterol/lipids

Prostate cancer

Other forms of cancer

Other illnesses

If yes for other illnesses, please list them here

LIFESTYLE INFORMATION

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?

Do you drink alcohol?

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) ?

MEDICAL HISTORY

Any known deficiency including minerals and electrolytes

Orthopedic or muscle disorder including fracture or joint disorders

Use of medications (if , list medications below)

Chemical Dependency

Blood disorders

Carpal Tunnel syndrome

Auto-immune system disorder

Heart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack

Cancer

Lung disorder

Allergies to Medications

Frequent upper respiratory infections

Edema / excess fluid retention

Poor wound healing

Emotional disorders / depression

Renal (kidney) disease

Genital – Urinary disorder

Hyperlipidemia

Hypertension (High blood pressure)

Neurological disorders

Thyroid, Diabetes or other endocrine disorder including insulin resistance

Arthritis

Bursitis

Rhuematoid arthritis

Sports Injury(s)

Heart attack (myocardial infarction)

Stroke

Other illnesses

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

Type/Dose/Frequency :

Do you currently have or have experienced any of the following symptoms?

If Yes, please check and explain below:

Increased lack of drive

Depression

Increasing fat deposits around the abdomen and/or thighs

Difficulty sleeping

Increasing mood swings

Increasing wrinkles

Progressive osteoporosis,decreasing bone density, or low trauma fractures

Headaches / Migraines

Increasingly stressed

Loss of concentration,sociability, activity

Hot flashes

Decreased desire and ability to exercise

Loss of interest in sex

Decreased energy or endurance

Muscle loss

Sore Muscles, joint pain(s) or swelling

Sagging, loose or thin skin

Thinning or loss of hair

Decreasing memory

Decreasing size of testicles

Decreasing muscle strength

Weight loss – Unexplained

Cold or heat intolerance

Other

Please use this space to explain any additional information