HEALTH EVALUATION FORM
The following questionaire is a comprehensive look at your health.
Full Name
*
First Name
Last Name
Gender
*
Male
Female
E-mail
*
Phone Number
-
Area Code
Phone Number
What are you primary health, performance, or longevity objectives?
*
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Begin
GENERAL INFORMATION
Name of Doctor or other health professionals you are currently seeing; Please be sure to include your Primary Health Care provider
Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height if known
Weight if known
What are the main reasons you are seeking health care?
*
Human Optimization
Longevity
Disease Prevention
Weight Loss
Digestive Support
Cardiovascular Protection
Stress Management
Dietary Advice
Energy
Immune System
Sports/Physical Enhancement
Pain Management
Other
The following three questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health
*
How do you rate your current level of energy or vitality
*
How do you rate your current stress levels
*
How many hours sleep do you get a night?
*
Do you have trouble getting to sleep?
*
No
Yes
Do you wake often, or get woken easily?
*
Yes
No
Do you have to go to the bathroom during the night?
*
Yes
No
Do you snore or have breathing problems during sleep?
*
Yes
No
Not sure
Do you have known allergies?
*
Yes
No
Please list any known allergies
*
Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives)
Please list any supplements you are currently taking
Do you have a main health complaint? Please describe.
Are there any of the following medical conditions in your family history that you are aware of? Please tick all that apply.
Arthritis
Asthma
Autoimmune Disorders (e.g. lupus, rheumatoid arthritis)
Bowel Disorders
Cancer
Dementia / Alzeihmers
Depression
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Low Blood Pressure
Mental Illness
Muscular Dystrophy
Obesity
Osteoporosis
Osteoporosis
Skin Disorders
Strokes
Thyroid Over Active
Thyroid Under Active
Other
Additional info you might want to share
Next: Diet and lifestyle . .
Back
Next
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
Please list the types of exercise you do regularly
Do you smoke?
*
Yes
No
How many per wk?
Do you take recreational drugs?
Yes
No
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?
*
Do you drink alcohol?
Yes
No
How many per week?
*
Back
Next
Patient health history
Frequency of exercise (days per week):
*
6 - 7
3 - 5
1 - 2
0
Vegetarian or vegen:
*
No
Yes
Age >50 years:
*
No
Yes
Planning to have a baby in the next 3-6 months:
*
No
Yes
Pregnant or breastfeeding:
*
No
Yes
Back
Next
Do you diet often?:
*
No
Yes
Are you unhappy with your weight?:
*
No
Yes
Back
Next
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
*
REVIEW OF SYSTEMS:
Are you experiencing any of these symptoms
General Health
None
Decreased Energy
Fever
Weakness
Chills
Fatigue
Night Sweats
Decreased Appetite
Sleeping Changes
Unexpected Weight Loss
Unexpected Weight Gain
Skin
None
Increased Body Odor
Skin Infections
Rashes
Color Changes
Changes in Hair
Nail Changes
Acne
Itchy Skin
Excessive Sweating
Wrinkles
Facial Hair
Varicose Veins
Hematologic
None
Easy Bruising
Swollen Glands
Abnormal Bleeding
Anemia
Frequent Infections
Diabetes Screen
None
Craving for sweets
Irritability if meal missed
Frequent urination
Palapitations after sweets
Extreme thirst
Peripheral Numbness
Central Nervous System
None
Headache
Syncope
Trouble Walking
Double Vision
Tremor
Dizziness
Paralysis
Seizure Disorder
Paralysis
Tingling, Numbness
Pain
Eyes
None
Gluacoma
Vision Loss
Excessive tearing
Glasses
Excessive redness
Contacts
Ears
None
Drainage
Pain
Discharge
Hearing Loss
Nose, Throat, Sinuses
None
Frequent Sore Throat
Trouble Swallowing
Nose Bleeds
Voice Changes
Tumors
Nasal Drainage
Sinusitis
Gums and Teeth
None
Dentures
Bleeding Gums
Abscesses
Bad Breath
Respiratory
None
Frequent Colds
Shortness of Breath
Blood in sputum
coughing
wheezing
Chest pain while breathing
Heart
None
Chest pain with exertion
abnormal blood pressure
chest pain at rest
irregular heart beat
heart beat too fast/slow
trouble breathing laying down
pain in left arm
heartburn after eating
leg cramps/heaviness with walking
Gastrointestinal
None
Abdominal pain
Diarrhea
change in bowel habits
constipation
blood in stool
nausea
black stools
vomiting
heartburn
hemorrhoids
vomiting blood
food intolerances
Urinary Tract
None
Painful urination
Nighttime urination
Blood in Urine
increased frequency
hesitancy
Decreased stream
Kidney stones
Dribbling or loss of bladder control
frequent infections
Musculoskeletal
None
muscle pains
deformity
joint pains
back pain
arthritis
limitation of movement
Edema
Male Reproductive
None
Testicular Mass
Painful Intercourse
Infertility/Low Sperm Count
Penile Discharge
Past or Present penile rash
STDs
Increased sexual desire
Lower sexual desire
Poor quality erections
Female Reproductive
None
vaginal discharge
vaginal dryness
painful intercourse
breast lumps
heavy menstrual period
hot flashes
irregular periods
night sweats
water rentention
insomnia
menstrual pain
poor sexual desire
STDs
Nose, Throat, Sinusses
None
Increased Body Odor
Skin Infections
Rashes
Color Changes
Changes in Hair
Nail Changes
Acne
Itchy Skin
Excessive Sweating
Wrinkles
Facial Hair
Varicose Veins
Pysch
None
Nightmares
Anxiety
Hallucinations
Insomnia
Suicidal Thoughts
Depression
Homicidal thoughts
Use of antidepressants
Mood swings
Nervousness
Short attention span
Difficulty concentrating
Anger outbursts
Fear of losing control
Negative thought loops
Depression/sadness
Your Preferred E-mail Address
*
Finish
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