Medical HistoryArthritisAllergies/hay feverAsthmaAlcoholismAlzheimer’s diseaseBlood pressure problemsBronchitisCancerChronic fatigue syndromeCarpal tunnel syndromeCholesterol, elevatedCirculatory problemsColitisDental problemsDepressionDiabetesDiverticular diseaseDrug addictionEating disorderEpilepsyEmphysemaEyes, ears, nose, throat problemsEnvironmental sensitivitiesFibromyalgiaFood intoleranceGastroesophageal reflux diseaseGenetic disorderGlaucomaGoutHeart diseaseInfection, chronicInflammatory bowel diseaseIrritable bowel syndromeKidney or bladder diseaseLearning disabilitiesLiver or gallbladder disease (stones)Mental illnessMental retardationMigraine headachesNeurological problems (Parkinson’s, paralysis)Sinus problemsStrokeThyroid troubleObesityOsteoporosisPneumoniaSexually transmitted diseaseSeasonal affective disorderSkin problemsTuberculosisUlcerUrinary tract infectionVaricose veins

Other_________________________________________________________

Medical (Men)Benign prostatic hyperplasia (BPH)Prostate cancer

Decreased sex driveInfertilitySexually transmitted disease

Other_____________________________________________________________

Medical (Women)Menstrual irregularitiesEndometriosisInfertilityFibrocystic breastsFibroids / ovarian cystsPremenstrual syndrome (PMS)Breast cancerPelvic inflammatory diseaseVaginal infectionsDecreased Sex DriveSexually transmitted disease

Other_____________________________________________________________Age of first period __________________Date of last gynecological exam _______Mammogram + -PAP + -Form of birth control ________________# of children ______________________# of pregnancies ___________________

C-section _____________________Surgical menopauseMenopause

Date of last menstrual cycle __________Length of cycle ______________daysInterval of time between cycles _______ daysAny recent changes in normal menstrual flow (e.g., heavier, large clots, scanty) _________________________________

Family Health History(Parents and Siblings)

ArthritisAsthmaAlcoholismAlzheimer’s diseaseCancerDepressionDiabetesDrug addictionEating disorderGenetic disorderGlaucomaHeart diseaseInfertilityLearning disabilitiesMental illnessMental retardationMigraine headachesNeurological problems (Parkinson’s, paralysis)Sinus problemsObesityOsteoporosisPneumoniaStrokeSuicide

Other____________________________

Health HabitsTobacco:

Cigarettes: # / day __________________Cigars: # / day _____________________

Alcohol:Wine: # glasses / d or wk ____________Liquor: # ounces / d or wk ____________Beer: # glasses / d or wk _____________

Caffeine:Coffee: # 6 oz cups / d _______________Tea:# 6 oz cups / d _________________Soda w/ caffeine: # cans / day _________Other sources _____________________

Water: # glasses / d _____________

Exercise5-7 days per week3-4 days per week1-2 days per week45 minutes or more duration per workout30-45 minutes duration per workoutLess than 30 minutesWalkRun, jog, jump ropeWeight liftSwimBoxYoga

Nutrition & DietMixed food diet (animal and vegetable sources)VegetarianVeganSalt restrictionFat restrictionStarch / carbohydrate restrictionThe Zone DietTotal calorie restriction

Specific food restrictions:dairy wheat eggssoy corn all gluten

Other_____________________________

Food FrequencyServings per day:Fruits (citrus, melons, etc.) ___________Dark green or deep yellow / orange vegetables ________________________Grains (unprocessed) _______________Beans, peas, legumes _______________Dairy, eggs ________________________Meat, poultry, fish __________________

Eating HabitsSkip breakfastTwo meals / dayOne meal / dayGraze (small frequent meals)Food rotationEat constantly whether hungry or notGenerally eat on the runAdd salt to food

Current SupplementsMultivitamin / mineralVitamin CVitamin EEPA / DHAEvening Primrose / GLACalcium , source _______________MagnesiumZincMinerals, describe ______________Friendly flora (acidophilus)Digestive enzymesAmino acidsCoQ10Antioxidants (e.g., lutein, resveratrol, etc.)Herbs – teasHerbs – extractsChinese herbsAyurvedic herbsHomeopathyBach flowersProtein shakesSuperfoods (e.g., bee pollen, phytonutrient blends)Liquid meals

Other_____________________________

Would you like to:Have more energyBe strongerHave more enduranceIncrease your sex driveBe thinnerBe more muscularimprove your complexionHave stronger nailsHave healthier hairBe less moodyBe less depressedBe less indecisiveFeel more motivatedBe more organizedThink more clearly and be more focusedImprove memoryDo better on tests in schoolNot be dependent on over-the-counter medications like aspirin, ibuprofen, anti-histamines, sleeping aids, etc.Stop using laxatives or stool softenersBe free of painSleep betterHave agreeable breathHave agreeable body odorHave stronger teethGet less colds and flusGet rid of your allergiesReduce your risk of inherited disease tendencies (e.g., cancer, heart disease, etc.)