Patient Medical History Quality of Life Assessment Copy of Government ID Patient Consent Name*Date Gender:MaleFemaleWeight:Height:Section 1: Patient History: Check all that apply to your current health as well as your past medical history. Heart Disease Arthritis Lupus or Rheumatoid Arthritis Memory Problems Fluid retention (e.g. swollen ankles/legs) Wheezing Certain foods cause ill feelings Total blood cholesterol above 200 Thinning/loss of outside portion of eyebrow Shortness of breath Previous use of HRT/anabolics steriods Lung Disease (i.e. asthma, emphysema) Stomach/Esophagus Disorders (i.e. reflux) Substance Abuse (i.e. alcohol, drugs, etc...) Anemia HIV/AIDS Frequent urination or scant urination/dribbling Headaches Problems with attention and concentration Excessive stress Rapid mood swings Lack of self-esteem Cancer Liver Disease (i.e. hepatitis, cirrhosis) Gland Disorders (thyroid, adrenal, pituitary) Skin and Hair Problems Cannot tolerate much exercise Rapid heartbeat, fluttering Difficulty gaining weight Hypersensitive to the cold Apathy/lethargy Difficulty getting out of bed in the morning Other symptoms (please list in blank boxes) Abnormal EKG Bowel Disease (i.e. malabsorption, lactose, IBS) Weight Control Problems Chest pain while walking or running Feel faint or weak Abdominal pain Lack of early morning erections Sexual drive under active Back pain Impatient, moody, nervous Sleep disturbances High Blood Pressure Mental Health Issues (i.e. depression, anxiety) Allergies Recurring upper respirtory infection/colds Difficulty breathing Difficulty lying flat Difficulty losing weight Cold hands and feet Insomnia Use of erectile enhancement meds (e.g. viagra) Neurological Disorders (i.e. stroke, seizures) Kidney Disease (i.e. stones, infections, cysts) Bladder disease Osteoporosis Sleep Apnea/Snoring Overweight Dependency on Antacids Hearing loss Sinus infections Carpal Tunnel Syndrome Depression Section 1: Patient History: Check all that apply to your current health as well as your past medical history.Untitled Missed periods Pre-menstrual syndrome (PMS) Dislike of intercourse Menstrual pain Infertility History of uterine cysts/fibroids Hot flashes/night sweats Bloating and swelling Previous or current hormone treatment Heavy menstrual bleeding History of miscarriages History of endometriosis Under active sex drive Tender breasts Use of oral contraceptives Irregular periods History of ovarian cysts Recent pap smear Have you had a hysterectomy? If yes, please provide the date and reason.Date of your last menstrual period?Pap smear (female)Month:Year: Pelvic ExamMonth:Year: Breast exam (female)Month:Year: Mammogram (female)Month:Year: ColonoscopyMonth:Year: SigmoidoscopyMonth:Year: Rectal examMonth:Year: Stress EchoMonth:Year: Nuclear StressMonth:Year: Chest X-rayMonth:Year: Eye exam/pressuresMonth:Year: Stress EKGMonth:Year: Resting EKGMonth:Year: Prostate exam(male)Month:Year: Personal Physician Info:Name:Number:Emergency Contact Info:Name:Number:Specialist Physician Info:Name:Number:Family History: Heart Disease Lung Disease Prostate Cancer Diabetes Thyroid Section 4:Past Surgical History:Please list any medications you are currently taking:Please explain any checked boxes on Section 1 of the medical history formCAPTCHA Patient Name:Date 1. I have to struggle to finish tasks:YesNo2. I feel a strong need to sleep during the day:YesNo3. I often feel lonely even when I am with other people:YesNo4. I have to read things several times before they sink in:YesNo5. It is difficult for me to make friends:YesNo6. It takes a lot of effort for me to complete simple tasks:YesNo7. I have a difficult time controlling my emotions:YesNo8. I often lose track of what I want to say:YesNo9. I lack confidence:YesNo10. I have to push myself to do things:YesNo11. I often feel very tense:YesNo12. I feel as if I let people down:YesNo13. I find it hard to mix with people:YesNo14. I feel worn out even when I've not done anything:YesNo15. There are times when I feel very low:YesNo16. I avoid responsibilities if possible:YesNo17. I avoid mixing with people I don't know well:YesNo18. I feel as if I'm a burden to people:YesNo19. I often forget what people have said to me:YesNo20. I find it difficult to plan ahead:YesNo21. I am easily irritated by other people:YesNo22. I often feel too tired to do the things I ought to do:YesNo23. I have to force myself to do all the things that need doing:YesNo24. I often have to force myself to stay awake:YesNo25. My memory lets me down:YesNo This iframe contains the logic required to handle AJAX powered Gravity Forms. Patient Name:Spectrum Health Medical Spa requires a patient to supply our medical practice with a copy of a valid state identification or U.S Passport before they may begin a therapy program. A failure to supply Spectrum Health Medical Spa with identification will automatically disqualify a prospective patient from receiving treatment.File This iframe contains the logic required to handle AJAX powered Gravity Forms. Patient Consent for the Use & Disclosure of Health InformationName:Date Name:Relationship:Phone:Name:Relationship:Phone: This iframe contains the logic required to handle AJAX powered Gravity Forms.
