Health for Life
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Name
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Date of Birth
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MM
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DD
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YYYY
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Address
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Phone Number
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Email
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Marital Status
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Married
Single
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How did you hear about us?
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Please list your greatest health concerns in order of priority.
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1
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2
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3
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What do you believe is causing your most important health concerns?
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Please list any medications and supplements you are currently taking, along with doses and the reason you are taking them.
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Have you had any surgeries in the past?
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Please list any major illnesses you currently have or have had in the past.
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Current Health Concerns
Please check normal or abnormal. If abnormal, please explain.
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Constitutional (Energy, weight, body temperature, sleep, general sense of well-being)
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Normal
Abnormal
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If abnormal, please explain:
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Vision/eye problems
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Normal
Abnormal
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If abnormal, please explain:
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Ear/nose/throat/mouth (allergies, infections etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Cardiovascular: (high BP, low BP, cholesterol etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Respiratory
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Normal
Abnormal
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If abnormal, please explain:
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Digestive tract issues: (acid reflux, changes in bowel habits, hemorrhoids, bloating, pain, etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Musculoskeletal concerns (arthritis, joint problems, osteoporosis, muscle pain, weakness)
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Normal
Abnormal
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If abnormal, please explain:
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Skin (eczema, infections, rashes, etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Psychological (mood changes, sadness, irritability, anxiety etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Neurological (numbness, tingling, balance problems, headaches, memory etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Hormonal issues (thyroid problems, menopausal, adrenal, testosterone, etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Blood or lymph issues (current anemia, swollen glands etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Allergies (drugs, supplements, foods, environmental, etc.)
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Normal
Abnormal
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If abnormal, please explain:
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Other
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Normal
Abnormal
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If abnormal, please explain:
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General
Please fill in what you can.
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Height
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Weight
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Cholesterol (Total, LDL, HDL, Triglycerides)
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Blood Pressure
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Family History
Please list any major illnesses or chronic conditions in the following family members:
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Mother
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Father
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Siblings
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Maternal Grandmother
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Maternal Grandfather
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Paternal Grandmother
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Paternal Grandfather
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Diet
Please briefly describe a typical day's diet for you (be honest!).
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Breakfast
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Lunch
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Dinner
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Snacks
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Social History
Please list sources and amounts of:
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Caffeine
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Alcohol
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Smoking history and amount
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Recreational drugs
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Lifestyle
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What is your vocation?
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What are your primary sources of stress?
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What do you do to manage stress?
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Do you exercise? What is your exercise routine?
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