Date:____________

Name:____________________ Date of birth:____________ Age:_____ Sex:_____
Occupation:________________________ Years worked at this job?______

Marital Status: __Single __Partner __Married __Separated __Divorced __Widow (er)
Family History:

               Name         Age                Health problems              Cause of Death     Age

Mother:__________| _______| ___________________________| ____________| _______

mgm:  __________| _______| ___________________________| ____________| _______

mgf:    __________| _______| ___________________________| ____________| _______

Father:__________| _______| ___________________________| ____________| _______

pgm:   __________| _______| ___________________________| ____________| _______

pgf:     __________| _______| ___________________________| ____________| _______

Sibs:   __________| _______| ___________________________| ____________| _______

          __________| _______| ___________________________| ____________| _______

          __________| _______| ___________________________| ____________| _______

          __________| _______| ___________________________| ____________| _______

List all health problems and/or disabilities you have been treated for throughout your life:
Year Treated:     Health Problem:         Treatment:

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

List major hospitalizations:
Year Treated:| Operation, Illness, Injury:| Outcome:

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

__________| ____________________| _________________________________________

___________| _______________________| ___________| _______________________

___________| _______________________| ___________| _______________________

___________| _______________________| ___________| _______________________

___________| _______________________| ___________| _______________________

Note all current OTC’s and amounts (use back if necessary):
 Medication         |       Amount          |         Medication          |         Amount

___________| _______________________| ___________| _______________________

___________| _______________________| ___________| _______________________

___________| _______________________| ___________| _______________________

___________| _______________________| ___________| _______________________

Note all current supplements and amounts (use back if necessary):
         OTC         |        Supp Amount          

___Arthritis
___Allergies/hayfever
___Asthma
___Alcoholism
___Alzheimer’s
___Autoimmune disease
___Blood pressure problems
___Bronchitis
___Cancer
___Chronic fatigue syndrome
___Carpal tunnel syndrome
___Cholesterol, elevated
___Circulatory problems
___Colitis
___Dental problems
___Depression
___Diabetes
___Diverticular disease
___Drug addiction
___Eating disorder
___Epilepsy
___Emphysema
___Eyes, ears, nose, throat problems
___Environmental sensitivities
___Fibromyalgia
___Food intolerances
___Gastroesophageal reflux disease
___Genetic disorder
___Glaucoma
___Gout
___Heart disease
___Infection, chronic
___Inflammatory bowel disease
___Irritable bowel syndrome
___Kidney or bladder problems
___Learning disabilities
___Liver or gallbladder disease
___Mental illness
___Mental retardation
___Migraine headaches
___Neurological problems
___Obesity
___Osteoporosis
___(Parkinson’s, paralysis)
___Pneumonia
___Sexually Transmitted Disease
___Seasonal affective disorder
___Sinus problems
___Skin problems
___Stroke
___Thyroid trouble
___Tuberculosis
___Ulcer
___Urinary tract infection
___Varicose veins
___Other

Medical (Men Only)
___BPH
___Prostate cancer
___Decreased sex drive
___Infertility
___Sexually transmitted disease
___Other
Do you perform monthly Testicular self-examination? ___ No ___Yes

Medical (Women Only)
___Menstrual irregularities
___Endometriosis
___Infertility
___Fibrocystic breasts
___Fibroids/ovarian cysts
___PMS
___Breast cancer
___Pelvic inflammatory disease
___Vaginal infections
___Decreased sex drive
___Sexually transmitted disease
Age at first period:______
Date of last menstrual cycle:______
Length of cycle______days
# days from beginning of one cycle to the next______
Date last GYN exam:______
Date last Mammogram:______ Results:________
Date last PAP:______ Results:_______________
Form of birth control:_____________________
# of pregnancies______ # of children______
# of C-section______
Surgical menopause, date:______
Natural Menopause, date:______
If female, do you perform Breast self-examination monthly?___ No ___Yes
    If not monthly, how often?________________

General Questions:
List your blood type. Type_____ Rh_____   
Have you ever had a blood transfusion?
___No ___Yes, year received_________. 
Any adverse reactions?
Sun exposure?________________
SPF# routinely used:______________
Last dental exam:_______________________
Do you have dentures? ___No ___Yes
Do you have any sores in your mouth? ___No ___Yes
Do you have trouble hearing? ___No ___Yes
Do you use a hearing device? ___No ___Yes
Do you wear glasses / contacts? ___No ___Yes
Have you had a recent change in your ability to: __see  __hear  __taste   __smell 
        __feel hot/cold sensations __move around __sit upright __stand  __walk  __run
        __pick up things  __swing your arms freely __turn your head   __wiggle fingers

Exercise:
___5-7 days/wk
___3-4 days/wk
___1-2 days/wk
___45 min or more/workout
___30 to 45 min/ workout
___Less than 30 min/workout
___Walk
___Run, jog, jump rope
___Weight lift
___Swim
___Box
___Yoga
Do you consider yourself:  __under weight __over weight  __just right
How much do you think you weigh?____________
Have you experienced an unintentional weight loss or gain of 10 pounds or more in the last three months.  __No __Yes

Diets:
Describe your diet: 
     __Mixed food diet (animal & vegetable sources)   
     __Vegetarian  __Vegan  __Lacto-ovo vegetarian
     __Eat mainly fruits & vegies    
     __Eat whole grains, legumes, cereals    
     __Limit/avoid red meats  
     __Eat only fish
     __Eat only eggs, dairy
     __Eat no dairy   
     __Eat lo-fat    
     __High fiber diet     
     __Follow "The Zone" diet  
     __Restrict total calories
     __Salt restricted  
     __Fat restricted 
     __Starch/Carbohydrate/Sugar restricted
     __Specific food restriction: __dairy __wheat __eggs __soy __corn __all gluten
                                            __peanuts __sugar __Other_____________________
     __Eat recklessly and unabated most of the time.
     __Eat fried foods    
     __Eat sweets, sodas, ice cream     
     __Diet frequently   
     __Skip meals    
   Do you have a.....
        Strong like for any of the following?: __sour __sweet __bitter __rich/fatty
                                                            __spicy/pungent __salty
        Strong dislike for any of the following?: __sour __sweet __bitter __rich/fatty
                                                            __spicy/pungent __salty
List your four favorite foods:

        
List number of meals you eat per day_______
Eat out _______times a week.
List number of times you eat red meat per week_______
List Fluid Intake:
Alcohol:
     ___Wine: # glasses/ d or wk
     ___Liquor: # ounces/ d or wk
     ___Beer: #glasses/ d or wk
     ___Caffeine:
     ___Coffee
     ___Tea:
     ___Soda w/ caffeine: # cans/ d or wk
Other sources:
     ___Water: # glasses/ d
Do you use tobacco products? Type? __Cigarettes __Cigars __Pipes __Chew
Daily amount consumed:___________
Are you interested in quitting? __Yes __No

Preferences:
List the level of stress you are feeling on a scale of 1 to 10 (1 being the lowest):_________
Identify and list the major cause (s) of this stress:__________________________________
Do you consider yourself: __Underweight __Overweight __Just right
Unintentional weight loss or gain of 10 pounds or more in the last three months?__No__Yes
Is your job associated with potentially harmful chemicals and/or life threatening activities? If, Yes, List:_________________________________________________________________
Do you utilize any of the following: __Corrective lenses __Dentures __Hearing aid
     __Medical devices/prosthetics/implants, describe:___________________________
Recent changes in your ability to: __See __Hear __Taste __Smell __Feel hot/cold
     sensations __Move around (sit upright, pick up things, swing your arms freely, turn your
     head, wiggle fingers)
Do you:  __prefer warmth / __prefer cold /__no preference in foods, drinks, weather?
Is your sleep disturbed at the same time each night? __No __Yes, List time:____________