First Name

Last Name

Middle Initial

Social Security

Date of Birth

Height

Weight

Address

State

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City

Zip

home Phone

Cell Phone

Preferred Contact

Choose... email cell phone home phone

email

Marital Status

Ethnicity

Race

How Did You Hear about Us?

Preferred Language

Responsible Party/Guarantor/Legal Guardian Contact

Do You Smoke?

Do You drink alchohol?

Are You Sexually active?

Do You have multiple Sex Partners?

Do you have a sexually transmitted disease?

Do You use Narcotics?

Do You take prescription meds?

Highest Level Of Education:

School Attended:

Current Occupation:

Any work related stress?

N/A

Father

Mother

Sibling

Children

Anaemia	yes	no
Angina	yes	no
Anxiety	yes	no
Arthritis	yes	no
Asthma	yes	no
Atrial Fibrillation	yes	no
Blood Clots	yes	no
Bronchitis	yes	no
Cancer	yes	no
Cerebrovascular Accident	yes	no
Coronary Artery Disease	yes	no
COPD (Emphysema)	yes	no
Crohn's Disease	yes	no
Frequent Infections	yes	no
Gallbladder Disease	yes	no
GI Disorder	yes	no
Glaucoma	yes	no
Thyroid	yes	no

Heart Attack	yes	no
Heart Mumur	yes	no
Hepatitis A,B,C	yes	no
Hyperlipidemia	yes	no
Hypertenson	yes	no
Irritable Bowel Disease	yes	no
Lactose Intolerance	yes	no
Liver Disease	yes	no
Osteoporosis	yes	no
Peptic Ulcer	yes	no
Peripheral Vascular Disease	yes	no
Pneumonia	yes	no
Polysistic Ovarian Synd.	yes	no
Prostate Disease	yes	no
Renal (Kidney) Disease	yes	no
STD	yes	no
Sexual Problems	yes	no

Neurological History
Peripheral Neuropathy	yes	no
Tremors	yes	no
Difficulty Speaking	yes	no
Dizziness	yes	no
Migraines	yes	no
Light Sensitivity	yes	no
Nausea	yes	no
Weakness / Fainting	yes	no
Pain	yes	no
Numbness / Tingling	yes	no
Seizures	yes	no
Spinal Injuries	yes	no
Epilepsy	yes	no
Behavioral History
Depression	yes	no
Memory Loss	yes	no
Hallucinations	yes	no
Loss Of Pleasure	yes	no
Fatigue	yes	no
Weight Loss /Gain	yes	no
insomnia	yes	no
Anxiety	yes	no
Drug Use	yes	no
Alcohol Abuse	yes	no
Attention Problems	yes	no

Dermatology History
Rashes	yes	no
Lesions	yes	no
Skin Cancer	yes	no
Skin Melanoma	yes	no
Acne	yes	no
Wrinkles	yes	no
Age Spots	yes	no
Eczema	yes	no
Dryness	yes	no
Health Maintenance
Flu Vaccine	yes	no
Pneumonia Vaccine	yes	no
Tetanus Vaccine	yes	no
Hepatitis Vaccine	yes	no
Shingles Vaccine	yes	no
Gardasil Vaccine	yes	no
Mammogram	yes	no
PAP Test	yes	no
Physical Exam	yes	no
STD Exam	yes	no
EKG Exam	yes	no
Heart Stress Test	yes	no
AB Aneurysm Screen	yes	no
Colonoscopy Exam	yes	no