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Medical Questionnaire
Personal Information
First Name:*
Last Name:*
E-Mail:*
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
Marital Status:
Gender:
Date of Birth:*
 
Phone:*
Height:*
Weight:*
Reason for your visit:*
Previous Condition?*
Yes
No
Patient History
Who was your previous primary care physician (list name, address & phone)?*
List all medications & supplements that you are currently taking.*
List all medications & supplements that you have previously taken.*
List all drug allergies you currently have.*
List all other allergies you currently have.*
Date & reason of your last doctor visit.*
Date & conditions of your past surgical procedure(s).*
Date & conditions of your past hospitalization(s).*
How is your overall health? Please explain.*
How is your energy level?*
Explain your exercise routine. How often?*
How is your mental alertness?*
List the diseases that run in your family.*
Substance abuse? Please describe.*
Do you suffer from depression? Please describe.*
Alcohol: Drinks per week? Drinks per day? Please describe.*
Smoking: Packs of cigarettes per day? Please describe.*
Specific Disorders (Check all that apply)
Measles:
Mumps:
Chicken Pox:
Whooping Cough:
Scarlet Fever:
Pnemonia:
Bursitis:
Polio:
Reduced Vitality:
Arteriosclerosis:
Stroke:
Heart Problems:
Seizure Disorders:
Anxiety Disorder:
Elevated PSA Level:
Anemia:
Bulimia:
Anorexia:
Cirrhosis of the Liver:
Renal Failure:
Colitis:
Herpes:
Syphilis:
HIV Disease:
Chlamydia:
Angina Pectoris:
Tachycardia:
Hypertension(high blood presure):
Hypotension(low blood presure):
Tuberculosis:
Breathing Problems:
Asthma:
Chronic Bronchitis:
Chronic Cough:
Emphysema:
Chronic Sinusitis:
Allergic Sinus problem:
Chronic Allergic Rhinitis:
Sinus Headaches:
Chronic Colds:
Female Menopause:
Andropause - decreased potency:
Nervous Disturbances:
Loss of Memory:
Psychiatric Disturbances:
Decreased Sexual Potency:
Sleep Disturbances:
Dizziness:
Chronic Migraine:
Meningitis:
Jaundice:
Epilepsy:
Ear Infection:
Hearing Loss:
Nausea:
Rectal Bleeding:
Burning of Urination:
Breast Cancer:
Cervical Cancer:
Ovarian Cancer:
Prostate Cancer:
Enlarged Prostate:
Bladder Cancer:
Liver Disease:
Kidney Disease:
Hyperthyroidism:
Thyroid Disease:
Hypothyroidism:
Lupus Erythematosus:
Scleroderma:
Epistaxis (Nosebleed):
Chicken Pox:
Bacterial/Fungal Infection:
Hepatitis:
Glaucoma:
Loss of Appetite:
Rapid Weight Gain:
Rapid Weight Loss:
Digestive problem:
Acid Indigestion:
Stomach Ulcers:
Overweight problem:
Pancreatitis:
Pancreatic Insufficiency:
Leg Cramps:
Swollen Ankles:
Varicose Veins:
Joint Pain:
Back Pain:
Arthritis:
Leg Ulcers:
Arms/Legs tingling sensation:
Hands/Legs falling asleep:
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