Name
Age
Height
Weight
Birthdate
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Hampshire
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New York
North Carolina
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Email
Phone Number
Occupation
What is your greatest need or problem? (List the most important; then list other issues in order of importance):
Your current medical conditions or diagnoses:
Drug allergies:
Allergies to food, pollens, environment, etc:
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:
Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:
Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:
If you are you currently taking medication for a thyroid condition, which one and dose?
Do you use tobacco products?
Do you use caffeine products?
Do you use recreational drugs?
How much water do you drink in one day (24 hr)?
Is your drinking water from a:
Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):
When was your last general medical exam:
When was your last general medical exam:
When was your last prostate exam:
Were the results of your last prostate exam normal?
If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:
Men's Health Questions
Sigmoidoscopy or colonoscopy
In the past month, have you had little interest or pleasure in doing things, or felt down, depressed or hopeless?
Personal Medical History
Please indicate whether you have had any of the following medical problems (with dates).
Heart disease / date / please specify type
High blood pressure / date
High cholesterol / date
Diabetes / date
Asthma/Lung disease / date
Kidney disease / date
Thyroid problem / date
Cancer / date / please specify type
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