PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION Name (last, first, middle initial) Home Address City Home Phone Age Sex F M Marital Status M S D Social Security Number State Work Phone Employer Birth date Zip Code Cell Phone Job Title Email Address Emergency Contact (Name)/relationship Personal Physician Preferred Pharmacy How did you learn about us / Referred by: Contact (phone 1) Physician Fax Pharmacy Fax Contact (phone 2) Physician Phone Pharmacy Phone REASON FOR CONSULTATION What health concerns and symptoms bring you to our office? Please be specific. What would you most like to achieve with this health consultation? MEDICAL HISTORY Please check any condition that you currently have or have had in the past. Headaches (migraines, other) Yes No Heart disease Yes No Seizures disorder Recurrent sinus Infections Seasonal allergies Psychiatric/emotional illness Depression Anxiety or excessive stress Asthma Chronic bronchitis Lung or breathing problems Chronic indigestion Stomach ulcers Intestinal disease Skin problems/dermatitis Back pain or sciatica Herniated disc Neck pain Chronic muscle or joint pain Carpal tunnel syndrome Fibromyalgia Diabetes Thyroid disease Osteoporosis/osteopenia Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No Chest pain Irregular heart beat High blood pressure Blood clotting problems Bleeding disorder Stroke/vascular disease Constipation/diarrhea Hepatitis/liver disease Kidney disease Menstrual disorders Reproductive problems Prostate problems Sexual/libido problems Tendonitis Chronic pain problems Shoulder pain Osteoarthritis Rheumatoid arthritis Artificial joint/implants Cancer Psoriasis or eczema Insomnia Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No Provide explanations and list any additional health problems below: List any surgeries/operations you have had and the year you had them: Year Surgery/Operation Are you currently under the care of a health professional for any medical condition? Yes No If yes, please provide name and explain condition and treatment (Note: Do not put meds here) List any medications you are currently taking or have taken in the recent past. Medication Name Date Started Date Stopped Dosage (amount/# daily) List any vitamins, herbs or nutritional supplements that you are taking. Medication Name Date Started Date Stopped Dosage (amount/# daily) List any medication allergies that you are aware of: List any environmental/food allergies that you are aware of: Preventive Tests History Month/Year of last test Cholesterol Bone density Colonoscopy Exercise stress test Test Results MEDICAL HISTORY – FEMALE (MEN, PLEASE SKIP TO NEXT PAGE) Are you currently pregnant? Yes No First day of last cycle? How many children? Yes No Yes No No How many pregnancies have you had? Do you perform monthly self breast exams? Had a hysterectomy? Yes If yes, were your ovaries removed? Has your abdominal girth and weight been increasing? Yes No Have you had any menstrual irregularities? Yes No If yes, explain below: Are you taking or have you taken hormones or oral contraceptives Yr Started Yr Stopped Yes No If yes, please list all hormones and oral contraceptives you have taken below: List hormones or contraceptives here Have you ever had any problems or concerns about taking hormone replacement therapy? Yes No If yes, explain below: Month/Year of last test Pap/pelvic exam Breast exam Mammogram Test Results Please check those conditions that you currently have or have had in the past Condyloma Memory lapse Yes No Yes No Decreased libido Dizzy spells Painful or difficult urination Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No Menopause Dribbling Mood swings Frequent nightime urination Pelvic pain Painful intercourse Frequent urination Excessive itching Sexually transmitted disease Sore breasts Vaginal dryness Vaginal itching Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No Excessive urination Hair growth on face Hair loss Blood in urine Hot flashes Irritability Snoring Stress incontinence Urge incontinence Recurrent UTI’s Vaginal discharge Yes Yes No No Vaginal odor Weird dreams Yes Yes No No Explain yes answers below as needed: MEDICAL HISTORY – MEN ONLY Date of last prostate exam Are you concerned with loss of muscle mass, tone or strength Do you perform periodic testicular self examination Has your abdominal girth and weight been increasing Benign prostate hypertrophy Circumcism Decreased libido Condyloma Dribbling Painful urination Bed wetting Erectile dysfunction Frequent urination Blood in urine Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Hesitancy (urination) Incontinence Frequent nightime urination Prostate cancer Prostate problems Sexually transmitted disease Swelling of penis Testicular pain or swelling Uretheral discharge Recurrent urinary tract infections Explain yes answers below as needed: FAMILY HISTORY Mother living? Father living? Family disease history Heart disease High blood pressure Diabetes Arthritis Skin disorders Breast cancer Uterine/Ovarian Cancer Prostate cancer Colon cancer Other cancer Yes Yes No No If no, provide age at death If no, provide age at death Write relationship of the relative(s) with the disease on the adjacent lines Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No List any other diseases/conditions in the family and the relationship SOCIAL HISTORY GENERAL Overall health Physical fitness level Excellent Excellent Yes No Yes No Good Good Fair Fair Poor Poor Yes No Yes No Under a lot of stress Fatigued all the time Yes No Having difficulty dealing with stress Often sad and blue Practice meditation or other relaxation techniques Dietary Habits No special dietary habits Try to eat a healthy diet True True Avoids red meat Min carbs True True Chocolate Yes True Minimizes fat Vegetarian True True True Yes Yes Yes Emphasize fruits, grains and vegetables Commonly eat at fast food restaurants Commonly consume: Coffee Commonly consume: Candy Exercise Habits No special exercise habits Aerobic exercise: Jog Stretch/Yoga/Tai Chi Yes Yes Avoids dairy/cheese Commonly eat chocolate Yes Yes Diet soda Chips Regular soda True True True Routinely exercise Walk True week Treadmill True Other Lift weights hrs True Swim x/week True Tobacco Use I never smoked cigarettes or chewed tobacco I now smoke I quit smoking in (mo/yr) Alcohol Use I never drink alcohol of any kind I regularly drink: 1-2 drinks/day Over 4 drinks/day True True I smoke cigars/pipes True years. Yrs. packs of cigarettes per day. I have smoked for I smoked packs/day for s m o True I drink occasionally or socially k True e Over 2 drinks/day True d drink (wine, beer, other) I typically True Hobbies/Sports/Recreation List routine hobbies/sports/recreational activities: ______________________________________ Patient Signature ________________ Date Methods of completing and submitting this form: You may complete this form in ink, sign it and fax it to us at (888) 205-7932. You may complete this form on your computer using Microsoft Word, type your name in the signature box and submit it via fax as above or via the Proactive Secure Portal. This HIPAA-compliant portal provides encrypted email over SSL to ensure absolute security and privacy. To use the secure email feature, go to www.proactivesecureportal.com, register using the on-screen registration instructions and send a secure email to email@example.com. PLEASE DO NOT SUBMIT THE FORM BY ORDINARY EMAIL. Note: To meet the needs of all of our patients, we require as much advance notice of cancellation as possible. If your cancellation is less than 48 hours prior to your appointment or you do not show, your credit card will be charged for the appointment and a rescheduling fee may apply. Our complete cancellation policy is provided on our web site at www.proactivewellness.com. Click on fees and payment.
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