Patient Medical History
General Information and Medical History (All Patients and Consults) Date ____________ Name _______________________________________________ Date of Birth ____________ Gender (circle one) Male Female Age ____________ SSN _____ - ____ - _____ &/or Driver's Lic. #_______________________ exp __________ City/St/Zip ________________________ Address _______________________________ Marital Status (circle one) : single married divorced widowed Contact Phone Numbers: Best _____________ Alternate: ____________ Email: __________________________________ Preferred method of contact: (Circle all that apply) email phone call text Emergency Contact Info: Name __________________________________________ Relationship ____________ Contact Numbers: Best _____________ Alternate: ________________ Primary Care Physician: __________________________ OB/GYN: _________________ Please list all current prescription medication(s) prescribed by a health care professional: Drug Dosing #/day which Dr. Why
Please list all current OTC (over-the-counter) medication. (Include vitamins, supplements, herbs, etc) Med. Name Dosing #/day Medically suggested/Self taken
Do you have any drug or food allergies? (circle one) Yes No Unsure If yes, which drug(s) and/or food(s): ______________________________________ Are you allergic to sulfa and/or red dye? (circle one)
Yes
No
Unsure
Please list any surgeries (including pregnancies) and corresponding MM/YY:
Please list any medical problems you have had, and the age you first diagnosed with this condition. (use the back of this sheet if necessary).
General Information and Medical History, continued Are you planning on having any/additional children? Yes No Women: Date of Last Menstrual Period: _______________________________________ Women: Have you had a hysterectomy? Yes No If yes, do you still have your ovaries? Yes No Have you ever had any form of cancer? Yes No If yes, please explain: ________________________________________________________ Have you ever had a heart attack or been told you have heart blockage? Yes No If yes, please explain: _________________________________________________________ Have you ever had a blood clot? Yes No If yes, when? ______________________ Do you have a clotting disorder? Yes No If yes, ____________________________ Does anyone in your family have a clotting disorder? Yes No If yes, whom? ______________________________________________________________ Have you ever had a stroke or a mini stroke (TIA)? Yes No If yes, when? ________________________________________________________________ Please circle all illnesses you have been treated for (items not circled are understood to be negative). abnormal bleeding epilepsy/seizure rheumatic fever emphysema/COPD liver disease urinary problems
ulcer hepatitis high blood pressure anemia gout perpheral vascular disease anxiety diabetes sexual dysfunction asthma kidney disease polycystic ovarian disease depression arthritis autoimmune disease prostate issues osteoporosis/osteoperia Family History This is important in determining your overall medical history. Please include medical problems and age of death, if applicable.
Mother
Father
Brothers/Sisters
Children
Social History Do you use tobacco of any kind? (circle one) Yes No How often? _____________ Do you drink alcohol? Yes No How often? __________________________
General Information and Medical History, continued Social History Do you have a good support system for a wellness program? ______________________ What diets have you tried? List all that apply and any results: ______________________ __________________________________________________________________________ BLOOD WORK - EARLY DETECTION If you have had any of the following tests, please indicate approximate date of testing and the result (what did your MD prescribe):
___ cholesterol/lipid blood test _____________________________________ ___ cardiac stress test _____________________________________ ___ chest X-Ray _____________________________________ ___ colonoscopy _____________________________________ ___ pelvic ultrasound _____________________________________ ___ mammogram _____________________________________ ___ papsmear _____________________________________ STRESS ANALYSIS Rate your stress from 1 (low) to 10 (high): 1 2 3 4 5 6 7 8 9 10 What are your sources of stress? _____________________________________ __________________________________________________________________ How do you cope (or relieve yourself from stress and frustration)? _________ __________________________________________________________________ GOALS Please share with us your health goals, why you are here for this consultation, and your desired results from this program. Please INCLUDE your goal weight and most common foods you enjoy. Also include any other information you feel may help us in determining the best course of action for your body's ideal well-being. ____________________________________________________ ___________________________________________________________________ ___________________________________________________________________ __________________________________________________________________________ What are you interested in? (Please select all that apply) _____ Hormone Therapy/Optimization _____ Food Allergy Testing _____ General Health and Wellness
_____ Medical Weight Loss _____ Image Related Services _____ Supplements
Release of Medical Records I understand the above information will be kept confidential and is accurate to the best of my knowledge. I hereby give authorization for Body Shapes Medical to release all pertinent information regarding my past medical history, lab results, and any other confidential chart information to: ____________________________________________________ Physician Name or Medical Facility ____________________________________________________ Address and Phone
___________ DOB ____________ Date ____________ Date
Client Name Printed Client Signature BSM Staff
Thank you. We look forward to helping you reach your goals and create your best body!
"A Better You Begins Inside." IP 100 Rev 11/18/14
Name ____________________________________ Date ________________ D.O.B. ______________ Health Assessment for Dietary Supplementation Y
N
5HTP Do you want to overeat, binge eat? Are you moody? Do you have poor sleep? Do you use or have you used pain medications recently? Do you drink alcohol at least 3 times a week? Are you on an anti-depressant medication?
Y
N
Arterial Therapy Do you have a history of poor circulation? Do you have high blood pressure? Do you have a history of high cholesterol? Are you on blood thinning agents, including daily aspirin?
Y
N
Bio-Zyme Do you bloat after meals? Do you tend to feel you don't burn the calories you did when you were younger? Do you have stomach ulcers?
Y
N
Buffered, Corn Free Vitamin C Do you experience fatigue? Do you have allergies? Do you easily bruise? Do you have bleeding gums? Do you have kidney problems? Do you have any other area of blood loss (menstruation)? Do you have high blood pressure? Are you overwhelmed by daily tasks, have a very busy life, or feel stressed most of the time?
Y
N
Cortisol Manager Do you have trouble getting to sleep? Do you sleep straight through the night? Do you wake feeling that you haven't rested? Do you feel O.K. in the morning but exhausted by afternoon? Do you feel tired in the morning but wired at night? Do you have excess fat on your stomach?
Y
N
Are you over 40? Is healthy aging important to you?
Has any medical professional restricted you on any nutrient(s) or type of food intake? Do you have a medically diagnosed food allergy? Do you have diabetes or have been told you are pre-diabetic?
Are you anxious, ready to get things done now? Are you stressed? Do you feel overwhelmed by the amount of tasks you need to accomplish each day? Do you run a marathon life each day but are not tired? Do you have memory recall problems? Do you have chronic inflammation? Have you been diagnosed with Addison's Disease? Clinical Nutrients for Women and Men Do you want to be sure you are consuming the essential daily requirements for vitamins and minerals, and co-supportive factors for healthy aging &/or weight management? Are you female, over 45, but still menstruating? Are you female, under 45, but no longer menstruating due to a surgical procedure?
Y
N
Vitamin D3 Do you get enough sun exposure in spring/summer months? In winter months? Do you have a history of less than perfect bone health? Do you have high cholesterol?
Y
N
Detox Weight Manager Have you had (or are now at) a plateau of weight loss? Do you have a sluggish metabolism? Will your weight loss consist of a large amount or rapid loss of stored fat?
Y
N
DHEA Are you exhausted? Do you have low levels of reproductive hormones? Are you overwhelmed by daily tasks, have a very busy life, or feel stressed most of the time?
Y
N
Eskimo 3 Y Do you consume oily fish (herring, sardine, tuna, salmon) at least 3x per week? Please indicate which fish and how often per week _________________________________________ Do you crave fatty foods, fried foods, oily foods (peanut butter, hummus), or potato chips? Is your skin prone to wrinkling? Do you have dry skin or scalp? Do you have or have you had a history of high cholesterol? Do you have inflammation and pain in the body or joints? Are you moody? Do you have a hard time focusing? Do you have PMS? Do you have hot flashes? Are you on any blood thinning agents, including a daily aspirin?
N
Ginkgo Biloba Do you have circulation problems?
N
Y
Do you have a loss of sexual sensation or erectile dysfunction? Do you have memory recall problems? Are you depressed? Are you on blood thinning agents, including a daily aspirin? Glycemic Manager Has your doctor ever spoken to you about watching your sugars, starches, carbs? Has your glucose ever been higher than what it should be? Have you been told you are at risk for diabetes or pre-diabetes?
Y
N
Glycation Manager Are you diabetic? Do you want to prevent wrinkling of skin? Do you want to slow down the accelerated aging that can be caused by char-grilled food, air pollution, sugars, alcohol, or smoking? Do you have an elevated Hemoglobin A1c?
Y
N
Indolplex Do you have PMS? Do you have uterine fibroids, breast cysts or tenderness? Do you have prostate problems? Are you exposed to a lot of chemicals in your job? Do you have excess fat that can contribute to hormone imbalance? Do you use Hormone Replacement Therapy? Do you have a history of cancer of the reproductive tissues (breast, uterus, endometrial, ovary, prostate?)
Y
N
Krebs Magnesium Potassium Chelates Do you have fatigue? Do you have headaches (migraine or muscle tension)? Do you have relentless or inability to sleep well? Do you have muscle cramps? Do you have PMS? Do you tend to be constipated? Do you have hypertension? Do you have kidney failure or kidney function problems?
Y
N
Lavela Do you experience daytime anxiety? Do you experience poor sleep or trouble sleeping? Are you moody and anxious? Are you overwhelmed by life or have chronic stressors? Do you drink wine/alcohol at least 2-3x a week to relax? Do you take anti-anxiety medication?
Y
N
Physicans Weight Manager Do you need help to stop food cravings?
Y
N
Do you find it difficult to consume enough protein? Do you need help preparing a meal that would be high in fiber to satisfy but very low calorie, while giving you the protein you need? Do you have a medically diagnosed milk allergy? PanPlex 2 Phase Do you feel bloated after you eat? Do you experience abnormal fullness for a long time or flatulence after you eat? Do you rush your meals? Do you have stomach ulcers, gastritis, or reflux?
Y
N
Probiotics Do you have symptoms of flatulence, loose stool, constipated, and cramping? Are you lactose intolerant? Do you have rapid transit (food leaving quickly) after meals? Have you used antibiotics more than once/yr without taking probiotics afterward? Have you been medically diagnosed with a milk allergy (not a sensitivity)?
Y
N
Resveratrol Is it difficult to burn fat even though you exercise regularly?
Y
N
Rhodiola Do you have chronic stress? Do you drink caffeine and have problems sleeping? Do you get irritable when you drink caffeine? Do you consider yourself extremely anxious?
Y
N
Theracurmin Do you have a lot of pain due to inflammation? Do you have a family history of neurological disorders (dementia, Alzheimer's, Parkinson's)? Have you been diagnosed with cancer? Do you smoke? Are you regularly around others that smoke? Have you been told your liver function is not normal? Do you now drink, or have had, alcohol 3x/week consistently in the past?
Y
N
UBQH Do you have a history of muscle weakness or fatigue? Do you have high blood pressure or heart muscle weakness (heart attack, stent, bypass)? Are you on a statin drug?
Y
N
Items in italics are a potential contraindication = 1/28/2014
