CASE HISTORY

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					CASE HISTORY
LAST NAME_______________________ FIRST NAME__________________ DATE_________________ ADDRESS______________________________________ TELEPHONE______________________________ _____________________________________________ CODE_______________________________ AGE__________________ SEX_________ CHILDREN__________ ZIP

MARITAL STATUS______________

OCCUPATION/ RETIRED?_________________________________________ DURATION_________________________

FAMILY HISTORY:( Of disease)
FATHER_______________________________________________________________ __________________ MOTHER:______________________________________________________________ _________________ GRAND PARENTS______________________________________________________________ ___________ WIFE/HUSBAND:_______________________________________________________ _________________ BROTHERS/SISTERS:___________________________________________________ __________________

PATIENT HISTORY:
MAJOR ILLNESSES:____________________________________________________________ _________ OPERATIONS:__________________________________________________________ ________________

PRESENT COMPLANTS:

________________________________________________________________ _________________ ________________________________________________________________ _________________ ________________________________________________________________ _________________ ________________________________________________________________ _________________ ________________________________________________________________ ___________________ ________________________________________________________________ __________________ ________________________________________________________________ ___________________ ________________________________________________________________ _____________________ ________________________________________________________________ ______________________ PHYSICAL CHARACTERISTICS:
WEIGHT:__________________ POSTURE______________________ HEIGHT________________________ SKIN TYPE (Oily,dry,normal)___________________________

BIOLOGICAL AGE:
EFFECTS OF EXCERCISE: Jog with a stop clock. The moment you start jogging start the stop clock How long can you jog without breathing heavily? stop the stop clock as soon as heavy breathing starts, indicate the time in minutes and seconds. TIME:____________________. How many stairs can you comfortably climb, before you feel breathless? NO OF STAIRS: ______________________

For how long can you stand on one leg? TIME:_______________________

MENTAL CHARACTERISTICS:(Depressed,aggressive,irritable,sensitive,easy to stess)
________________________________________________________________________ _____________________ ________________________________________________________________________ __________________________ ________________________________________________________________________ _____________________

HOW WOULD YOU CATEGORISE YOURSELF?
Tired in the morning/afternoon/evening/chronically tired.____________________________________________ Your diet?_(please specify)_________________________________________________________________ ___ _______________________________________________________________________ ___________________ Do you drink or smoke? (Please specify)_________________________________________________________ ________________________________________________________________________ ___________________

ALLOPATHIC TREATMENT:
PRESENT/PREVIOUS:( Give details of date, duration). ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ please answer yes or no and give a brief detail of the problem.

Any problems with;

SKIN:__________________________________________________________________ _______________ NOSE:_________________________________________________________________ ________________ HEAD:_________________________________________________________________ __________________ EYES:_________________________________________________________________ __________________ EARS:_________________________________________________________________ __________________ FACE:_________________________________________________________________ ___________________ TEETH:________________________________________________________________ ___________________ MOUTH:_______________________________________________________________ __________________ THROAT:______________________________________________________________ ___________________ THIRST:_______________________________________________________________ ______________________ DIET:__________________________________________________________________ _____________________ APPETITE:_____________________________________________________________ _________________________ ABDOMEN:____________________________________________________________ ______________________

STOOL:________________________________________________________________ _______________________ URINE: _______________________________________________________________________

GENITALS: ________________________________________________________________________ _______ LUNGS:________________________________________________________________ ____________________ CHEST:________________________________________________________________ _____________________ HEART:________________________________________________________________ ____________________ SPINE:_________________________________________________________________ ____________________ FEVER:________________________________________________________________ _____________________ ALLERGIES:___________________________________________________________ ______________________ DESIRES/AVERSIONS (e.g, like sweet food, desires warmth) ________________________________________

DREAMS:_______________________________________________________ _________________ LIMBS:________________________________________________________ __________________ BLOOD (High or low blood pressure):__________________________________________________
Would you prefer, food supplements, nutritional therapy or other alternative therapies in your anti-aging plan? ________________________________________________________________________ _______________ ________________________________________________________________________ ______________________ ________________________________________________________________________ __________________________ Please indicate your correct age and any diseases,

paying special attention to your family history for a properly tailored anti-aging plan.

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