Health Questionnaire

Please correct the errors described below.

This form is to get some more health history information about you before you come to your visit.

Patient Name

First, Last

Patient Date of Birth

Please select all the immunizations you have had previously.

Tetnus

Influenza

Pneumococcal

Hep A Series

Hep B Series

Gardasil (HPV)

Shingles Vaccine

Vericella

Have you ever had Chicken Pox?

Yes

No

Past Testing and Procedure History

Please select all that apply

Bone Density Test

Colonoscopy

Heart Stress Test

Heart Catheterization

PSA Test

Mammogram

Pap Smear

Colposcopy

Pregnancy

Given Birth

Consulting Physicians

Cardiologist

Please Type Name of Doctor & Phone Number

Endocrinologist

Please Type Name of Doctor & Phone Number

Gatroenterologist

Please Type Name of Doctor & Phone Number

OB/GYN/Urologist

Please Type Name of Doctor & Phone Number

Ophthamologist

Please Type Name of Doctor & Phone Number

Orthopedist

Please Type Name of Doctor & Phone Number

Nephrologist

Please Type Name of Doctor & Phone Number

Podiatrist

Please Type Name of Doctor & Phone Number

Please briefly describe any current health issues, aliments or concerns you are "currently" experiencing.

Are you allergic to any medications that you are aware of? If "YES" please list them in the next box.

Yes No Known Drug Allergies (NKDA)

List of Medications allergic to:

Past Medical History Please Check all that apply

No Past Medical Issues

High Blood Pressure

High Cholesterol

Diabetes

Thyroid Disease

Heart Disease

Unexplained Weight Loss

Unexplained Weight Gain

Anemia

Stroke

Cancer

Diagnosed

If you have checked any past illness please tell us when you were diagnosed. Also if you have any other medical conditions not listed above.

List all Current Medications

Parathyroid/Bone

Please check all that apply

Increased thirst/urination

History of Kidney Stones

Use of Antacids

Bone Pain

Use of Calcium Supplements

Muscle aches

Loss of height

History of Fractures

Family History of Osteoporosis

Adernal

Please check all that apply

Darkening of skin/gums

Salt Craving

Skin Stretch Marks

Easily Bruised

Diarrhea/Vomiting

Change in Facial Appearence

Excess hair growth over face/chin/chest or abdomen

Difficulty raising arms over head

Other

Please check all that apply

Menstrual Irregularities

Hot Flashes

Impotence

Decreased Libido

Erectile Dysfunction (ED)

Decreased Hair Groth/Balding

List any other symptoms you would like to discuss

We will make every effort to discuss your medical concerns at your visit. However, we may need to schedule an additional appointment to adequately address multiple concerns. Thank you

I HAVE READ AND ANWSERED THE PATIENT REGISTRATION FORMS AND MEDICAL QUESTIONNAIRES TO THE BEST OF MY ABILITIES.

Please check box and type name below as your authorized electronic signature. Thank you

Electronic Signature

Please type First, Last Name

Date Signed

Your information will be encrypted.

This form is to get some more health history information about you before you come to your visit.

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