Medical History and Present Medical Condition Questionnaire Medical History and Present Medical Condition Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastDateHEALTH CONDITIONSDo you currently have or have you recently had any of the following? Ear, Nose and Throat (Check all that apply)AllergiesHearing lossFrequent nosebleedsFrequent sinus troubleFrequent hoarsenessRinging/buzzing earsEarachesOther ear, nose, throat conditions:Eyes and Vision (Check all that apply)Poor night visionChange in visionBlurred or double visionGlaucomaOther eye / vision conditions:Neurological and Cognitive (Check all that apply)EpilepsyConvulsions/seizuresAnxietyDepressionMood disorderTrouble thinking and / or rememberingDizzinessFrequent headachesTremorsMemory lossLoss of coordinationDifficulty concentratingNumbness / tingling extremitiesOther mental health conditions:Other neurological/cognitive conditions:Mouth and Oral Health (Check all that apply)Bleeding gums and / or sore mouthTooth decayBad breathOther mouth / oral health conditions:Lungs and Airway (Check all that apply)AsthmaShortness of breathChronic or frequent coughBrown/blood-tinged sputumChest tightnessWheezingOther lung / airway conditions:Heart and Circulation (Check all that apply)Fainting or lightheadednessHeart attackHeart murmurPositive stress testHeart valve abnormalityAnginaHeart failureHigh blood pressurePalpitation (irregular heartbeat)Pain or discomfort in chestHigh cholesterolStrokeSwelling of feetLeg pain while walkingPainful varicose veinsBleeding / bruising easilyAnemiaOther heart / circulation conditions:Skin (Check all that apply)EczemaPsoriasisAcneSkin cancerFungal infectionsOther skin-related conditions:Sleep (Check all that apply)Sleep apneaSnoringInsomniaOther sleep-related conditions:Genito-urinary (Check all that apply)Kidney diseaseProstatitisUrinary tract infectionDifficulty starting/stopping urinationUrinating 2 or more times per nightFrequent or painful urinationOther genito-urinary conditions:Gastrointestinal (Check all that apply)Trouble swallowingGERD/heartburnFrequent indigestionUlcerVomited bloodHepatitisLiver diseaseElevated liver enzyme testHerniaBloating and / or gasCrohn’s / Colitis / IBDPersistent diarrheaPersistent constipationFrequent abdominal painFrequent nauseaBlack/bloody bowel movementHemorrhoidsKnown food allergies (causing anaphylaxis or hives):Known food intolerances:Other gastrointestinal conditions:Hormones (Check all that apply)Thyroid conditionsDiabetesTrouble controlling blood sugarSex hormone imbalanceLow or high cortisolOther hormonal conditions:Musculoskeletal (Check all that apply)Back trouble/painNeck trouble/painJoint injury/pain/swellingCarpal tunnel syndromeOther musculoskeletal conditions:Immune & autoimmune (Check all that apply)Swollen glandsRheumatoid arthritisLupusChronic fatigue syndromeOther immune/ autoimmune conditions:Miscellaneous (Check all that apply)CancerUndesired weight lossMen’s health (Check all that apply)ProstatitisLow testosteroneInfertilityTrouble with sexual functionOther men’s health conditions:Women’s health (Check all that apply)PCOSInfertilityEndometriosisPainful menstruationPMSHot flashes / night sweatsTrouble with sexual functionOther 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 NoIf so, are you getting a regular period?Yes or NoIf no, are you:Peri-menopausalMenopausalHave you had a Pap smear in the last 5 years?Yes or NoAre you on hormone replacement or hormonal birth control? If yes, what?Yes or NoHow often do you visit the doctor for a check-up?Monthly or moreEvery few monthsOnce or twice a yearEvery 2-5 yearsWhat’s a doctor and why would I visit one?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 USEDo you take any over-the-counter or prescription medications occasionally or regularly?Yes or NoAre 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 NDo 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?I don’t drink alcohol at allAbout once a month or fewerAbout once every 2 weeksAbout once a weekMore than once a weekDailyEach 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 all1 drink2-3 drinksMore than 3 drinksHow often do you use recreational drugs?I don’t at allAbout once a month or fewerAbout once every 2 weeksAbout once a weekMore than once a weekDailyDo you smoke? If yes, how many packs a day?Did you smoke in the past? If yes, when did you quit?Further informationIf you ticked off any health issues in the “Health conditions” section, please give more details.MessageSubmit