Please, enter your first name followed by last name
Please enter height in feet then leave a space and then height in inches
Other physicians you are currently seeing. Please, include name and contact information.
ALLERGIES
Please, write in None, if no allergies to any medications
Please list any allergy to foods, clothing, latex, pets, bees, etc. in this section
Current Medications
Please, list all current prescription medications, including dosage. Type in none if no current meds.
Please, list all non-prescription medications
Please, list all supplements/vitamins you are currently taking
Current Medical Problems
Please, check the appropriate box for currently active medical problem or diagnosis.
Please select all that apply.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please select all that apply. If selected other, please write in medical problem below.
Please list any current medical problems not included in the lists above. Please also indicate if you currently have cancer.
Past Medical Problems
Indicate history of previous medical problems
Other Medical Problems in the past that are no longer active
Please, list type of cancer and indicate whether in remission or resolved completely
Past Surgical History
Please select all that apply.
Please, list prior surgeries not listed above and include approximate dates
Family History
Please select all that apply.
Please list family members with corresponding illness, ie. paternal grandmother, maternal grandfather, mother, father, siblings. Please also list other relevant family history not included in the list above
Occupation/Social History
In addition to occupation, other responses for this field are student, retired, etc.
If former smoker, when did you stop smoking? If currently smoking, what products and how much do you use?
Please, include additional details about how much Alcohol you consume in a week and other details that you think would be relevant to your physical health and emotional health
Please, list any current or past Illicit Drug use, including Marijuana. Please, write none, if no current or past drug use.
Please select all that apply.
Choose the method you or your partner use for birth control. You may select more than one option.
Health Maintenance & Preventive Medicine
Please write name of doctor followed by month and year
Please write name of doctor followed by month and year
Please write name of doctor followed by month and year
Please, select all items that were checked/screened in the last 12 months
If you have had screening for items discussed above but it has been longer than 12 months, please write these items and your best guess when they were last checked, Month and Year preferably
Please write date of last tetanus shot in the blank. If your last tetanus shot was over 10 years or you can not recall the date of the last tetanus shot, write Unknown.
Please, check the box(es) corresponding to the vaccines you have previously received.
HEALTH GOALS
What are your health goals? You may choose more than one
May we have your permission to share your success story on our website. Please, select Yes or No from the drop down menu.
STOP: If you are participating in a Disease Reversal, My Best Health Plan or other specialized program with us, DO NOT complete the General Lifestyle Review below.
General Lifestyle Review
Please, select one item from the list above
Please, select the item(s) that best describes your food choices
Please, select all that apply
Please, select all that apply
Please, select all that apply
Please, indicate the type and amount of caffeine used in a day
Please, select all that apply
Give additional details on type of movement involved as part of everyday work and other forms of exercise not mentioned above. Also indicate how many minutes in a typical week do you move or exercise?
Please, select all the ways you use to manage stress
Please, select all that apply
Interest in making a POSITIVE CHANGE
