Download Fillable Client History Form (PDF) Step 1 of 5 20% Date MM slash DD slash YYYY Name First Last Date of Birth MM slash DD slash YYYY Age Home PhoneWork PhoneCell PhoneEmail Address SexFemaleMaleEmergency Contact Phone NumberHow did you hear about us? Occupation Marital StatusMarriedWidowedDivorced or SeparatedSingleHeight Weight Surgical HistoryList surgical procedures including plastic surgery.Other serious Illness/operationsDate of last chest x-ray MM slash DD slash YYYY Date of last EKG MM slash DD slash YYYY MedicationsNameDosageFrequency Allergies and type of reaction Medical HistoryHeart Disease Myself Family Clarifications Gall bladder disease Myself Family Clarifications Headaches Myself Family Clarifications Uterine Cancer Myself Family Clarifications Osteoporosis Myself Family Clarifications Diabetes Myself Family Clarifications Asthma Myself Family Clarifications Liver disease Myself Family Clarifications Ovarian Cancer Myself Family Clarifications Stroke Myself Family Clarifications Stroke Myself Family Clarifications Kidney disease Myself Family Clarifications Fibromyalgia Myself Family Clarifications Mental disorder Myself Family Clarifications Cervical cancer Myself Family Clarifications Varicose veins Myself Family Clarifications Seizures Myself Family Clarifications Arhtritis Myself Family Clarifications Thyroid disorder Myself Family Clarifications HIV/Aids Myself Family Clarifications Prostate cancer Myself Family Clarifications Clotting Myself Family Clarifications Colitis Myself Family Clarifications Breast cancer Myself Family Clarifications Nutritional SupplementsAndrostenedione Arimedex DHEA Estrace Estradiol Estriol Estrone Growth Hormone Human Growth Hormone Melatonin Pregnenolone Premarin Progesterone Provera Tamoxifen Testosterone Thyroid Vitamin A Vitamin B3 Vitamin B6 Vitamin B12 Vitamin C Vitamin D Vitamin E Beta Carotene Calcium Co Q10 Chromium Digestive Enzyme Folic Acid Iron Magnesium Selenium Zinc Probiotic SocialAlcohol use Yes No Amount Coffee Yes No Amount Soft drink Yes No Amount Tea Yes No Amount High sugar food Yes No Amount Chewing tobacco Yes No Amount Cigarettes Yes No Amount Excessive stress Yes No Amount Review of systemsCheck all that appliesHead Headaches Blurred vision Cloudy vision Hair Hair loss Dry hair Clumps of hair coming out Cardiovascular Water retention Cannot tolerate much exercise Difficult breathing Chest pain while walking Heaviness in legs Calf muscle cramp often Heart pounds easily Palpitations High blood pressure Low blood pressure Respiratory Shortness of breath Chronic lung congestion Wheezes Cough Acute congestion Gastrointestinal Constipation Diarrhea Heart burn Abdominal pain Certain foods cause ill feeling Blood in stool Epigastric pain Hernia Urinary Frequent Urination Burning with urination Incontinent issues Musculoskeletal Change in muscle mass Joint pain Limitation in motion Dermatological Dry skin Oily skin Acne Metabolic Difficulty gaining weight Difficulty losing weight Sensitivity to cold Wake up craving sweets Fatigue Feel faint Night sweats Increased thirst Craves sweets Weight loss more than 10 lbs in 6 months Weight gain more than 10 lbs in 6 months Psychological Rapid mood swings Moodiness/ change in mood Depression Lack of self-esteem Anxiety Difficulty concentrating Short attention span Forgetfulness Sleep Difficulty going to sleep Difficulty staying asleep Wake up frequently Hours of sleep per night Females OnlyFemales Only Bloating and swelling Breast tenderness Miscarriage Vaginal discharge Underactive sex drive Pelvic soreness Menstrual pain Insomnia Vaginal bumps/sores Premenstrual chest discomfort Hot flashes Night sweats Vaginal dryness Infertility Heavy menstrual bleeding Ovarian cysts Breast lump Irregular period Date of last menstrual cycle MM slash DD slash YYYY Date of last pelvic exam and pap smear MM slash DD slash YYYY Results Date of last Mammogram MM slash DD slash YYYY Sexually transmitted diseases Form of birth control None IUD Diaphragm Condom Pill Sponge Foam Other Males OnlyMales Only Pain with ejaculation Difficulty maintaining erection Sexual drive underactive Premature ejaculation Pain in genital area Infertility Low sperm count Discharge from penis Rash on penis Swelling in groin Loss of urine control Frequent urination at night Date of last prostate exam MM slash DD slash YYYY Results Last PSA blood level Do you use Viagra Yes No How often Does it help? Yes No Maybe Do you use any other medication for sexual function? Yes No Please list NameThis field is for validation purposes and should be left unchanged. Δ
