MEDICAL QUESTIONNAIRE

Name

Today's Date

Date of Birth

Gender

Address

Phone

Employer

Occupation

Emergency Contact

Relationship

Phone

Primary Care Doctor

Location/Phone Number

How did you hear about us?

Describe your symptoms

Medical History (list everything you have been diagnosed with)

Medications (Please list all prescription medications - doses and frequencies)

Medications (Please list all over the counter medications/supplements – doses and frequencies)

List any allergies to medications

Hospitalizations (List all hospitalizations and for what reason)

Surgical History (List all surgeries with dates)

If yes to any of the above, please note the age at which the family member contracted the disease. (i.e. Father: age 42)

Have either of your parents had a heart attack or a cardiac stent before age 60?

Yes

Please list any other diseases that run in your family

Your occupation for the past 10 years?

Marital Status?

Number of Children?

Have you ever smoked cigarettes, cigars, or pipes?

If yes, How many years? Have you quit? If so, when?

Have you smoked any cigarettes in the past month?

Yes

Have you ever used any recreational drugs?

Yes

How much alcohol do you drink in a week? One drink = 4 oz wine, 12 oz beer, 1 oz liquor.

Less than 2

2-5

6-14

15 or more

REVIEW OF SYMPTOMS - CHECK ANY SYMPTOMS YOU HAVE

SCALP/HEAD

Hair Loss

Scalp Tenderness

Headache

Jaw pain with chewing

ALLERGY

Frequent sneezing

Seasonal allergies

Increased infections

Men only: Do you have a decrease in libido (sex drive)?

Yes

Men only: Do you have a lack of energy?

Yes

Men only: Do you have a decrease in strength and /or endurance?

Yes

Men only: Have you lost height?

Yes

Men only: Have you noticed a decreased “enjoyment of life”?

Yes

Men only: Are you sad and /or grumpy?

Yes

Men only: Are your erections less strong?

Yes

Men only: Have you noted a recent deterioration in your ability to play sports?

Yes

Men only: Are you falling asleep after dinner?

Yes

Men only: Has there been a recent deterioration in your work performance?

Yes

Men only: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

Men only: Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

Men only: Over the past month, how often have you stopped and started again several times when you urinated?

Men only: Over the past month, how often have you found it difficult to postpone urination?

Men only: Over the past month, how often have you had a weak urinary stream?

Men only: Over the past month, how often have you had to push or strain to begin urination?

Men only: Over the past month, how many times did you get up to urinate during the night?

Men only: Increase or decrease of weight in the past 6 months? How much?

Women only: When was your last period?

Women only: When was the period before the last one?

Women only: At what age did you start menstruating?

Women only: How many days is it between periods?

Women only: How many days of flow do you have during your period?

Women only: How many of these are heavy flow?

Women only: Are your cycles regular?

Women only: Do you suffer from PMS?

Women only: Are you having painful periods?

Women only: Do you get breast tenderness at any time during your cycle? When?

Women only: Do you feel bloated during your cycle? When?

Women only: Do you get headaches at a particular time during your cycle?

Women only: Do you get more irritable or emotional before your period?

Women only: How many periods have you missed in the last year?

Women only: Do you have hot flushes?

Women only: Do you have vaginal dryness?

Women only: Is sexual intercourse painful frequently?

Women only: Do you have frequent yeast infections?

Women only: Do you have frequent urinary tract (bladder) infections?

Women only: On a scale of 1 to 10 (10 highest), how would you rate your sex drive?

Women only: Has your sex drive changed significantly since you were younger?

Women only: Has the quality, intensity, or frequency of your orgasms changed?

Women only: How many times have you been pregnant?

Women only: How many pregnancies resulted in a birth?

Women only: How did the other pregnancies end?

Women only: Are you having problems controlling urination?

Women only: Do you have abnormal vaginal discharge?

Women only: Increase or decrease of weight in the past 6 months? How much?

RECENT DIAGNOSTIC TESTS

Cholesterol

HDL

LDL

Triglycerides

Men only: PSA and date

Mammogram date and results (normal or abnormal)

Pap smear date and results (normal or abnormal)

Sigmoidoscopy date and results (normal or abnormal)

Colonoscopy date and results (normal or abnormal)

Cardiac stress test date and results (normal or abnormal)

Bone Density scan test date and results (normal or abnormal)

Describe your typical daily/weekly exercise routine:

List a typical day’s food and drink consumption:

Thanks for submitting!