Health Screening First Name(Required)Last Name(Required)Phone(Required)Email(Required)HEALTH SCREENINGHave the following changed in the last year - if yes - please give details:Appetite(Required) Yes No If “Yes” give detailsWeight(Required) Yes No If “Yes” give detailsSleeping Habits(Required) Yes No If “Yes” give detailsEnergy Level(Required) Yes No If “Yes” give detailsAmount of water you drink daily(Required) Yes No If “Yes” give detailsBowel movement or urination frequency(Required) Yes No If “Yes” give detailsDo you Exercise(Required) Yes No If “Yes” how oftenDo you smoke(Required) Yes No If “Yes” how oftenDo you drink alcoholic beverages(Required) Yes No If “Yes” how oftenDo you drink coffee or tea(Required) Yes No If “Yes” how oftenHave you ever had:If yes, please explainBlurred vision(Required) Yes No If “Yes” please explainRinging in your ears; loss of hearing(Required) Yes No If “Yes” please explainHead injuries/blackouts(Required) Yes No If “Yes” please explainRapid heart beat(Required) Yes No If “Yes” please explainPains, discomfort, or tightening in chest(Required) Yes No If “Yes” please explainDiscomfort or shortness of breath(Required) Yes No If “Yes” please explainPain or discomfort in arm, joint, leg(Required) Yes No If “Yes” please explainSwollen legs, ankles, feet(Required) Yes No If “Yes” please explainFrequent nausea or vomiting(Required) Yes No If “Yes” please explainDiscomfort when swallowing, after eating(Required) Yes No If “Yes” please explainFrequent diarrhea or constipation(Required) Yes No If “Yes” please explainPainful or bloody bowel movements(Required) Yes No If “Yes” please explainLoss of urine when laugh, sneeze, cough(Required) Yes No If “Yes” please explainTendency to bleed or bruise easily(Required) Yes No If “Yes” please explainOther:If Female:Are you pregnant? Yes No How many monthsAre you going through Menopause? Yes No Give detailsVaginal ilchlng, burning, discharge? Yes No Give detailsTender breasts, nipple discharge, lumps? Yes No Give detailsDate of last periodDate of last mammographyDate of last periodIf Male:Testicular masses, enlargement? Yes No Give detailsDifficulty starting urine stream sore on penis, discharge? Yes No Give detailsILLNESSES AND SYMPTOMSIndicate if you or a blood relative have ever had any of the following conditions. If “Yes” give dates and type of treatmentDiabetes or sugar in your urine(Required) Yes No Specify Relative Give detailsCancer or tumor(Required) Yes No Specify Relative Give detailsHeart trouble(Required) Yes No Specify Relative Give detailsEpilepsy/seizures/convulsions(Required) Yes No Specify Relative Give detailsHIV/AIDS(Required) Yes No Specify Relative Give detailsSickle Cell anemia(Required) Yes No Specify Relative Give detailsStroke(Required) Yes No Specify Relative Give detailsTuberculosis(Required) Yes No Specify Relative Give detailsSexually transmitted disease(Required) Yes No Specify Relative Give detailsThyroid problems or goiter(Required) Yes No Specify Relative Give detailsAllergies/asthma/hay fever(Required) Yes No Specify Relative Give detailsUlcers/stomach/duodenal(Required) Yes No Specify Relative Give detailsHepatitis(Required) Yes No Specify Relative Give detailsMumps(Required) Yes No Specify Relative Give detailsScarlet fever(Required) Yes No Specify Relative Give detailsChicken pox(Required) Yes No Specify Relative Give detailsMalaria(Required) Yes No Specify Relative Give detailsMeasles - Rubeola(Required) Yes No Specify Relative Give detailsGerman Measles - Rubella(Required) Yes No Specify Relative Give detailsRheumatic fever(Required) Yes No Specify Relative Give detailsParasites (Specify)(Required) Yes No Specify Relative Give detailsLupus(Required) Yes No Specify Relative Give detailsHigh cholesterol(Required) Yes No Specify Relative Give detailsHigh blood pressure(Required) Yes No Specify Relative Give detailsAnemia(Required) Yes No Specify Relative Give detailsEating disorder(Required) Yes No Specify Relative Give detailsOther:MEDICATIONList all medications that you are currently taking. Include prescribed and non-prescribed drugs, amount and frequency.medicationsAbove information completed by:EVALUATIONTo be completed by a nurse practitioner, physician, physician’s assistant or registered professional nurse:evaluationAbove information completed by: Δ
