Name____ Today’s date:
Phone (h)__(w)
Address____ Email
MEDICAL INFORMATION
When was your last complete physical examination?
What were the results?
List any medications you are currently taking, or have taken in the past 6 months.
Provide the reason they were prescribed.
List any operations that you have had (include date):
Are you on a special diet?
Have any member of your immediate family (mother, father, sister, brother) had:
Heart disease Hypertension High Cholesterol Heart Attack
Diabetes Stroke Obesity
Indicate any of the following which currently or have existed in the past, and note when:
Anemia Arthritis Asthma__ Back pain/injury_
Bursitis__ Cancer Diabetes Dizziness_
Epilepsy Headaches Heart problems__ Hernia _
Hypoglycemia__ Joint problems___ Kidney problems Liver disease
Lung disease Shortness of breath Ulcer Weight problems
Chest Pains High blood pressure Thyroid problems High cholesterol_
Osteoporosis___ Neurological Disorder_ Other__
Do you currently smoke? ___ Have you ever smoked? ____ Age: __
Are you pregnant or trying to become pregnant?_____
BLOOD PRESSuRE:
Explain your current eating habits
How many times do you eat per day?
Do you take any supplements?