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Consultation Form:

GENERAL INFORMATION

Your full name:
Your email address (e.g.: you)
Your phone number: (with country, city, area codes)
Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

Age:	Sex:	Male Female	Height:	Ft. In.	Weight:	lbs.

List any allergies you have to food or medications:

Have you ever had any life threatening allergic reaction?

Do you drink coffee, soda, and/or tea?

Do you drink alcohol?

If Yes,

What Types?
Beer
Wine
Liquor

How Often?
Times / Month

Do you smoke?

If Yes,
Tobacco Product:

Quantity per Day:

How Long? yrs.

Are you using any Recreational Drugs?

If Yes, Please List:

	Drug Name:	Frequency:
#1
#2
#3

Are you currently taking any Prescription Drugs?

If Yes, Please List:

	Drug Name:	Dosage:	Frequency:
#1
#2
#3
#4
#5
#6

Do you take any nutritional supplements?

If Yes, Please List:

Supplements:

Occupation, now or in the past?

What is your living situation?

How physically active are you?

Do you exercise?

If Yes, Please List:

	Exercise Type:	Frequency:
#1
#2
#3

Family Medical and Social History:

(Please Remove Any Conditions That Don't Apply)

PAST MEDICAL HISTORY

General: (Please Remove Any Conditions That Don't Apply) skin disease, rheumatic fever, scarlet fever, birth defects, usual childhood illness; please list Please Give Types & Explain for All that Apply:	Eyes, Ear, Nose, & Throat: (Please Remove Any Conditions That Don't Apply) vertigo, ear disease, deafness, glaucoma, cataracts, and blindness Please Explain for All that Apply:	Neuro: (Please Remove Any Conditions That Don't Apply) stroke, paralysis, tumor, seizures Please Explain for All that Apply:
Cardiovascular: (Please Remove Any Conditions That Don't Apply) abnormal heart rhythm, pacemaker, chest pain, heart attack, heart disease, high blood pressure, heart murmur, fainting spells, high cholesterol /triglycerides Please Explain for All that Apply:	Respirartory: (Please Remove Any Conditions That Don't Apply) bronchitis, asthma, emphysema, pneumonia, and tuberculosis Please Explain for All that Apply:	Digestive: (Please Remove Any Conditions That Don't Apply) acid reflux, ulcer, jaundice, gallbladder problem, hiatal hernia, diverticulitis, hepatitis Please Explain for All that Apply:
Blood & Endocrine Disorders: (Please Remove Any Conditions That Don't Apply) bleeding disorder, anemia, thyroid disorder, diabetes Please Explain for All that Apply:	Genitourinary: (Please Remove Any Conditions That Don't Apply) kidney stones, kidney disease, history of sexually transmitted diseases or currently Please Explain for All that Apply:	Genitourinary(cont.): (Please Remove Any Conditions That Don't Apply) Female: PMS bladder / urinary dysfunction Male: prostatism bladder / urinary dysfunction Please Explain for All that Apply:
Do you currently have or have you ever had Cancer? If Yes, Please Give Type & Explain:	Musculoskeletal: (Please Remove Any Conditions That Don't Apply) rheumatoid arthritis, gout, degenerative arthritis, bone deformity Please Explain for All that Apply:	Psych: (Please Remove Any Conditions That Don't Apply) manic depressive, depression/anxiety, suicidal tendency Please Explain for All that Apply:
Have you been admitted to the hospital during the last year? If Yes, List Dates and Reasons for Admittance:	Have you received Emergency Room Treatment in the last year? If Yes, List Dates and Reasons for Emergency Room Treatment:	Have you EVER had ANY Surgery? If Yes, List Dates and Reasons for Surgery:

Specialized Tests:

(Please Mark All That Apply)

TEST	DATE	RESULTS
EKG
Echocardiogram
Exercise Stress test
Chest X-Ray

CURRENT HEALTH STATUS

General: Blood Pressure: Pulse: (Please Remove Any Conditions That Don't Apply) unexplained weight loss, malaise, night sweats, chills, fever, environmental/ food allergy, hay fever Please Explain for All that Apply:	Skin: (Please Remove Any Conditions That Don't Apply) rash, sores Please Explain for All that Apply:	Eyes, Ear, Nose, & Throat: Do you Wear Glasses ? Date of Last Eye Exam: (Please Remove Any Conditions That Don't Apply) blurred vision, double vision, tunnel vision Please Explain for All that Apply:
Cardiovascular: (Please Remove Any Conditions That Don't Apply) chest pains, dizziness, shortness of breath, fainting spells, palpitations, swelling of extremities Please Explain for All that Apply:	Respirartory: (Please Remove Any Conditions That Don't Apply) asthma, wheezing, cough, frequent colds Please Explain for All that Apply:	Digestive: (Please Remove Any Conditions That Don't Apply) nausea & vomiting, heartburn, stomach ulcers, diarrhea, constipation, difficulty swallowing, Blood in stool, abdominal pain Please Explain for All that Apply:
Neuro: (Please Remove Any Conditions That Don't Apply) numbness, tremors, weakness, stroke, paralysis, seizure disorder Please Explain for All that Apply:	Blood,Glands, & Endocrine: (Please Remove Any Conditions That Don't Apply) enlarged glands, anemia, bleeding disorder, easy bruising, heat /cold intolerance, excessive thirst Please Explain for All that Apply:	Genitourinary: (Please Remove Any Conditions That Don't Apply) frequent or painful urination, blood in urine, difficulty urinating, bed-wetting, frequent nocturnal urination Please Explain for All that Apply:
Musculoskeletal: (Please Remove Any Conditions That Don't Apply) bone pain, back pain, muscle pain, joint pain/swelling, stiffness Please Explain for All that Apply:	Psych: (Please Remove Any Conditions That Don't Apply) depression/anxiety, recreational drug use Please Explain for All that Apply:	List & Explain Other Current Health Problems:

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