Your health history - Please print out this section and fill it out on paper.  You can also choose select all under edit, copy it, paste it into an email, answer the questions and email them to me. Answer your questions in all capital letters or highlight your answer some way.

Other Practitioners:

1. Do you have a personal Physician?

2.  Do you go to your physician for regular preventative care like cholesterol screening, pap smears, breast exams, prostate screening?

3.  Do you have any condition for which your physician has recommended further or regular follow-up?

4.  Are you now engaged in or have you engaged in an occupation that has health hazards like mining, deep-sea diving, asbestos exposure, heavy-metal exposure to lead or similar metals?

Tobacco Exposure History

1.  Do you use tobacco products now? Y  N

2.  If yes, what kind?  __cigarettes  __cigars  __smokeless

3.  Quantify how much of each category of tobacco you use each weekday?                                                                  Weekend?

4.  If you quit using tobacco, how long has it been since you completely quit?

5.  Are you exposed to secondhand smoke?  Y  N

 Where?  __home  __work  __recreation  How often?

6.  What issues have you had with your muscles now or in the past?  Injuries, illnesses, surgeries, therapy

7.  What issues have you had with your bones and joints now or in the past?  injuries, illnesses, surgeries, therapy

8.  Do you have any limitations due to pain, injury, surgery? Y  N

         If yes, what are they?

9.  Do you have other physical concerns?

Personal and Family History

Do you or any member of your family (Mother, Father, Brother, Sister, Aunt, Uncle, Grandparent) have any of the following problems?  Write the category Me, Father,  Maternal-Grandmother (mgm) etc…beside the category.

1.  Disease of the heart or its circulation?

2.  Stroke or other types of brain attacks?

3.  High Cholesterol or Low HDL Cholesterol

4.  High Blood Pressure.

5.  Diabetes or “Prediabetes”

6.  Lung Disease

7.  Cancer

8.  Obesity

9.  Death from any disease before age 55?

Below list any prescribed medication, herbs/supplements or over-the-counter medication you take.  Include vitamins, Tylenol or other over-the-counter medications if you need them more than once a week.  Include prescriptions you have been recommended to take that you don’t take or take irregularly?  Please include the name, mg. strength per dose, and the number of doses per day or per week.

Vitamins and other supplements

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3.

Over-the-counter (non-prescription) medications

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3.

Prescription Medications

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