Health History. Name: Date: Date of birth:

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Scarlett Rodgers
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1 Health History Name: Date: Date of birth: Your answers will give us a better understanding of your medical concerns and conditions. If you are uncomfortable with any questions, feel free not to answer them. Best estimates are fine; however, be specific whenever you can. Medications: Please list all prescription and non-prescription medications, vitamins and herbs. Medication/Supplements Dose (milligrams per pill, doses per day) Start date Reason ( Please use back of form if you need additional space.) Allergies or reactions to medicines: Personal medical history Please indicate whether you have had any of the following medical problems (Include dates to indicate when the problem occurred.) Heart disease/ Stroke: Y / N Date(s): Other (Specify): Date(s): High blood pressure: Y / N Date(s): High Cholesterol: Y / N Date(s): Diabetes (Specify Type.): Y / N Date(s): Polycystic Ovaries: Y / N Date(s): Bleeding/clotting Problems: Y / N Date(s): Alcoholism: Y / N Date(s): Rheumatoid arthritis: Y / N Date(s): Gout: Y / N Date(s): Aortic aneurysm: Y / N Date(s): Cancer (malignancy) : Y / N Date(s): Thyroid problems: Y / N Date(s): Depression/Anxiety: Y / N Date(s): Nerve problems (Specify.) : Y / N Date(s): Memory Concerns: Y / N Date(s): Poor blood flow to extremities: Y / N Date(s):

2 Page 2 Have you ever been hospitalized for illness? If so, please tell us when & why: Surgical history Please list all operations with the dates when they occurred: Social history Tobacco use Ø Cigarettes Never Date you quit smoking Ø Current smoker (number of pack per day) Ø Other tobacco (circle all answers that apply): Pipe Cigar Chewing tobacco; # of years you ve used Ø Are you exposed to second-hand smoke? Yes / No For how long? Alcohol use Other: Ø Do you drink alcohol? Yes / No How many drinks do you consume per week? Alcohol type Ø Does your alcohol consumption have you or others concerned? Yes / No Caffeine intake Coffee cups/day Tea cups/day Sodas per day Diet / Regular Weight Are you satisfied with your weight? Yes / No What is your goal weight? When did you last weigh your goal weight? How long were you at that weight? Nutrition: How many daily servings of the following do you typically have? Whole grains Fruits Vegetables How many times in one week do you consume the following items? Eggs Fish Chicken/turkey Red meat Butter Margarine Other high fat dairy products Other low fat dairy Fried foods High fat snacks What type of cooking oil do you use? Who prepares meals at home? How often to you eat out? Foods do you typically order? How do you rate your diet? (Please circle one.) Good Fair Poor

3 Page 3 History for Women: How many times have you been pregnant? How many deliveries? miscarriages? Menopause? Yes / No Hysterectomy? Yes / No When Ovaries removed? Yes / No Did you have any history of gestational diabetes? Yes / No High blood pressure or eclampsia with pregnancy? Yes / No Did any of your children weigh more than eight pounds at birth? Yes / No Review of Systems: Please circle any current symptoms you have on the list below. Constitutional: Ø Fever/chills/sweats Ø Unexplained weight loss/gain Ø Brittle nails/ Dry skin Ø Change in skin or hair texture Ø Inability to stand heat or Cold Inability to stand cold Ø Change in energy/increased weakness Ø Excessive thirst or urination Respiratory: Ø Cough/wheeze Ø Difficulty breathing Ø Snoring Ø Sleep apnea/cpap Eyes: Ø Change in vision (Explain.) Ear/Nose/Throat/Mouth: Ø Difficulty hearing/ringing in your ears Ø Hay fever/allergies Ø Problems with teeth/gums Skin: Ø Acanthosis nigricans (dark lines around neck or under arms) Ø Skin tags Ø Rashes

4 Page 4 Cardiovascular: Any Other Symptoms of concern? Please list: Ø Chest pain/discomfort Ø Palpitations (irregular or racing heart beat) Ø Swelling in feet or legs Ø Varicose veins Ø Unexplained shortness of breath upon exertion Ø Pain in extremities with exercise Genitourinary: Ø Unusual frequency of urination Ø Urinary incontinence Ø Problems with erectile function (male) Ø Low labido Ø Gastrointestinal: Ø Abdominal pain Ø Blood in bowel movement Ø Heartburn Ø Nausea/vomiting Ø Diarrhea/constipation Neurological: Ø Headaches Ø Light-headedness Ø Memory loss Ø Loss of coordination Ø Tingling, pain, or numbness in hands or feet Psychiatric: Ø Problems with sleep Ø Depression Ø Anxiety/ Panic attacks/ Manic episodes Ø Anger issues Ø Blood/Lymphatic: Ø Easy bruising/bleeding/ Unexplained lumps

5 Page 5 Family History of Medical Conditions Please indicate the current status of your immediate family members. Include if each person is alive or deceased; please list approximate age now or at time of death; if applicable, the cause of death; and any other relevant comments. Mother s mother Mother s father Father s mother Father s father Mother Father Sister (s) Brother (s) Daughter(s) Son(s) Note: conditions of particular interest include: Heart disease High blood pressure Heart attack High cholesterol Stroke Smoking Dementia/ other memory decline Sleep Apnea Diabetes Cancers Obesity Kidney Disease Autoimmune disorders Psychiatric Conditions Carotid artery disease Bleeding problems Additional Notes: Thank you for taking the time to provide us this valuable information

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Occupation Agency Code Work Location Work Supervisor Duty tel. # PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal