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MEDICAL QUESTIONNAIRE

Are any of the following diseases in your immediate family?
Have either of your parents had a heart attack or a cardiac stent before age 60?
Have you smoked any cigarettes in the past month?
Have you ever used any recreational drugs?
How much alcohol do you drink in a week? One drink = 4 oz wine, 12 oz beer, 1 oz liquor.

REVIEW OF SYMPTOMS - CHECK ANY SYMPTOMS YOU HAVE

GENERAL
Endocrine
SKIN
NEUROLOGIC
SCALP/HEAD
EYES
EARS
NOSE
MOUTH
ALLERGY
LUNGS
HEART
GI/Abdomen
Urology
Blood/Lymph
Psychology
Men only: Do you have a decrease in libido (sex drive)?
Men only: Do you have a lack of energy?
Men only: Do you have a decrease in strength and /or endurance?
Men only: Have you lost height?
Men only: Have you noticed a decreased “enjoyment of life”?
Men only: Are you sad and /or grumpy?
Men only: Are your erections less strong?
Men only: Have you noted a recent deterioration in your ability to play sports?
Men only: Are you falling asleep after dinner?
Men only: Has there been a recent deterioration in your work performance?

RECENT DIAGNOSTIC TESTS

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Optimal Wellness Medical Logo

616-301-7390

5070 Cascade Rd SE Ste 210

Grand Rapids, MI

49546

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© 2025 Optimal Wellness Medical. All Rights Reserved.

OPENING HOURS

Mon - Thu: 8:30am - 5:00pm

Friday - 10am - 4pm

​​Saturday: CLOSED

​Sunday: CLOSED

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Genius hits a target no one else can see.”


Arthur Schopenhauer

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