Health Screening

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Patient Information

Name

Email

Sex

Male

Female

Other

Sex: Other

Date of Birth

Height

Weight

Family Doctor

Family Doctor Phone

Family Doctor Address

Apt, suite, etc.

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City

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Zip code

Questions about your health

Are you allergic to or have you hade a bad reaction to any food or drugs?

Yes

No

If so, what was the medicine or food?

Allergic Reactions

Are you on a special diet?

Yes

No

If so, please give diet name/details:

Diet

Have you lost or gained more than 10 lbs. in 2 months?

Yes

No

Are you any medication that makes you lose or gain weight?

Yes

No

Name of Medicine

Do you wear contact lenses or glasses?

Yes

No

Do you have any nutritional/eating/digestive concerns?

Yes

No

Do you have any physical disabilities?

Yes

No

If yes, please give details

Physical Disability

Do you have asthma?

Yes

No

If yes, please give details:

Asthma details

Do you have seasonal allergies?

Yes

No

Have you had any operations?

Yes

No

Have you ever tested positive for tuberculosis (TB)?

Yes

No

Have you ever had any of the following?

Serious accidents

Yes

No

Epilepsy

Yes

No

Neuropathy

Yes

No

Diabetes

Yes

No

High Blood Pressure

Yes

No

Heart Attack or Heart Disease

Yes

No

Cancer

Yes

No

Stroke

Yes

No

Non-cancerous tumors

Yes

No

High Cholesterol

Yes

No

Anemia

Yes

No

Jaundice or Hepatitis

Yes

No

Thyroid Problems

Yes

No

Sexually Transmitted Diseases

Yes

No

Arthritis

Yes

No

Stomach Ulcer

Yes

No

Please provide more information if you have or have had any of these disorders

MALES Only: Have you ever had any of the following?

Please click next to continue

Have you had sexually transmitted illnesses?

Yes

No

If so, which ones

Male Sexually Transmitted Diseases

Have you fathered children?

Yes

No

Have you ever been operated on or treated for testicular/penile problem?

Yes

No

Have you ever had problems with sterility (infertility)?

Yes

No

Do you regularly see a urologist?

Yes

No

At what age did you 1st have sex?

N/A

Age

Male First Sex Age

Do you have any problems with your prostate or with urination?

Yes

No

Additional Information

FEMALES Only

Please click next

Are you pregnant or breast feeding?

Yes

No

Are you on any type of birth control?

Yes

No

If so, which one

Birth Control Type

Have you stopped any type of birth control because of side effects?

Yes

No

Birth Control Side Effects Discontinued Type

Do you intend to stop taking any birth control you are on for any reason?

Yes

No

Have you ever been pregnant?

Yes

No

How many times pregnant

How many pregnancies resulted in miscarriages or abortions?

How old were you when you first had sex?

N/A

Age

Female First Sex Age

How old were you when you got your period?

N/A

Age

First Period Age

How old were you when on your first pregnancy?

N/A

Age

First Pregnancy Age

Have you ever been operated on or treated for genital problems?

Yes

No

If so, which one(s)

Female Genital Problems

Are you regularly checked by a gynecologist?

Yes

No

Additional Information

MALES & FEMALES Only: Have you ever had any of the following?

Eye

Yes

No

Sinuses

Yes

No

Memory

Yes

No

Breathing

Yes

No

Bladder or Urination

Yes

No

Arm or Leg Movement

Yes

No

Hearing

Yes

No

Swallowing

Yes

No

Skin

Yes

No

Stomach

Yes

No

Bowels

Yes

No

Ear

Yes

No

Additional Information

Do you have any of these symptoms?

Fainting Spells

Yes

No

Loss of Concentration

Yes

No

Heart Pounding

Yes

No

Frequent Coughing

Yes

No

Swelling of Hands or Feet

Yes

No

Frequent Headaches

Yes

No

Night Sweats

Yes

No

Indigestions

Yes

No

Hemorrhoids / Rectal Bleeding

Yes

No

Chest Pain

Yes

No

Dizziness

Yes

No

Heart Fluttering

Yes

No

Coughing Up Blood

Yes

No

Throat Pain

Yes

No

Extreme Tiredness

Yes

No

Back Pain

Yes

No

Loose Bowels

Yes

No

Excessive Thirst

Yes

No

Do you have any medical concerns that we should know about at this time?

Yes

No

Medical Concerns

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