Medical History and Present Medical Condition Questionnaire – Annie Berryhill- Healthy Lifestyle Strategist & Coach

Name *

First

Last

Date

HEALTH CONDITIONS

Do you currently have or have you recently had any of the following?

Ear, Nose and Throat (Check all that apply)

Other ear, nose, throat conditions:

Eyes and Vision (Check all that apply)

Poor night vision
Change in vision
Blurred or double vision
Glaucoma

Other eye / vision conditions:

Neurological and Cognitive (Check all that apply)

Other mental health conditions:

Other neurological/cognitive conditions:

Mouth and Oral Health (Check all that apply)

Bleeding gums and / or sore mouth
Tooth decay
Bad breath

Other mouth / oral health conditions:

Lungs and Airway (Check all that apply)

Other lung / airway conditions:

Heart and Circulation (Check all that apply)

Other heart / circulation conditions:

Skin (Check all that apply)

Other skin-related conditions:

Sleep (Check all that apply)

Sleep apnea
Snoring
Insomnia

Other sleep-related conditions:

Genito-urinary (Check all that apply)

Other genito-urinary conditions:

Gastrointestinal (Check all that apply)

Known food allergies (causing anaphylaxis or hives):

Known food intolerances:

Other gastrointestinal conditions:

Hormones (Check all that apply)

Other hormonal conditions:

Musculoskeletal (Check all that apply)

Back trouble/pain
Neck trouble/pain
Joint injury/pain/swelling
Carpal tunnel syndrome

Other musculoskeletal conditions:

Immune & autoimmune (Check all that apply)

Swollen glands
Rheumatoid arthritis
Lupus
Chronic fatigue syndrome

Other immune/ autoimmune conditions:

Miscellaneous (Check all that apply)

Cancer
Undesired weight loss

Men’s health (Check all that apply)

Prostatitis
Low testosterone
Infertility
Trouble with sexual function

Other men’s health conditions:

Women’s health (Check all that apply)

Other women’s health conditions:

Are you:

Trying to conceive?
Currently pregnant?
Post-partum (up to 1 year)?
Breastfeeding?

Should you normally be menstruating regularly?

Yes or No

If so, are you getting a regular period?

Yes or No

If no, are you:

Peri-menopausal
Menopausal

Have you had a Pap smear in the last 5 years?

Yes or No

Are you on hormone replacement or hormonal birth control? If yes, what?

Yes or No

How often do you visit the doctor for a check-up?

Are you currently under a doctor’s care? If yes, for what?

Have you had any surgeries and / or been hospitalized in the last 10 years? If yes, what?

Are there any other significant health concerns that I haven’t asked about? If so, please tell me about them.

Are you experiencing any stresses, mood conditions, relationship difficulties, or substance-related conditions for which you would like resources or a confidential referral? If so, please describe briefly.

MEDICATION, DRUG, AND SUPPLEMENT USE

Do you take any over-the-counter or prescription medications occasionally or regularly?

Yes or No

Are you on hormone replacement / supplementation, or hormonal birth control? (e.g., testosterone, estrogen, birth control pill, Nuva Ring) If yes, what?

Do you take any sports supplements or “natural” health products occasionally or regularly? (e.g., creatine, BCAAs, gingko, ginseng, St. John’s Wort) If yes, what? Y N

Do you take any other vitamin or mineral supplements occasionally or regularly? (e.g., multivitamin, iron supplement) If yes, what?

How often do you consume alcohol?

Each time you consume alcohol, how many drinks do you have (one drink = 12 ounces of beer, 5 ounces wine, 1.5 ounces hard liquor)?

I don’t drink alcohol at all
1 drink
2-3 drinks
More than 3 drinks

How often do you use recreational drugs?

Do you smoke? If yes, how many packs a day?

Did you smoke in the past? If yes, when did you quit?

Further information

If you ticked off any health issues in the “Health conditions” section, please give more details.