contact7 ALL INFORMATION IS STRICTLY CONFIDENTIAL First Name *: Last Name: Date of Birth *: Age : Weight: Height(feet): ---4.14.24.34.44.54.64.74.84.95.05.15.25.35.45.55.65.75.85.95.105.116.06.16.26.36.46.56.66.76.86.96.106.117.07.17.27.37.47.5 Street Address: Phone *: City *: State *: Zip : Do you suffer from(Please number according to importance, 1 being most important): ADD/ ADHD/ Hyperactivity- Depression- Migraines- Anxiety- Fibromyalgia- Mood Swings- Autism/ Asperger’s- Head Injury- Panic Attacks- Compulsions/ Addictions- Irritable Bowel- Weight Gain- Medical History—(Family History) Cancer High Blood Pressure Overactive Bladder Compulsion/ Addictions High Cholesterol Over Weight Diabetes/ Insulin Resistance Irritable Bowel Parkinson Frequent urination Osteoporosis Thyroid Disorder Medical History—(Personal History) Cancer High Blood Pressure Overactive Bladder Compulsion/ Addictions High Cholesterol Over Weight Diabetes/ Insulin Resistance Irritable Bowel Parkinson Frequent urination Osteoporosis Thyroid Disorder Please list any diseases or conditions you have been diagnosed with: Please list all surgeries you have had or are scheduled for: Please list any allergies: What are the specific health related goals you want to achieve? List any concerns you may have? Do you regularly engage in any of the following? Consume Caffeine Crave sugar/ carbohydrates Drink alcohol Use tobacco Eat vegetarian diet Medication &/or Supplements Currently Taken Custom Crème AminoStat B5 Powder Biosis Bio Femme Coral Calcium Detoxinol Digest All DHEA 7Keto DHEA 5HTP GABA Iso Blast L-Dopa L-Taurine L-Typtophan Magnesium Mucuna Nattokinase DLPA Phosphatidylserine Phosphatidylcholine Statlyte Triplex UltraD Herbal / Supplements List Current Medications: Adderall Concerta Benzodiazapine (Xanax) Celexa Effexor Elavil Cortisol/Hydrocortisone Luvox Prozac Paxil Sinequan Ritalin Tofanil Wellbutrin Gabapentin Other: History of Drug Use Past Present Exercise Do you exercise How often? What intensity? What type? Symptoms Do you have frequent aches or pain: ---YesNo Bruise easily: ---YesNo Puffy eyes: ---YesNo Dark circles around eyes: ---YesNo Brittle Nails: ---YesNo Acne/itchy/blotchy skin: ---YesNo Memory loss: NoYes ---Short TermLong Term Do you frequently feel: NoYes ---HotColdFatiguedSweat at Night Sleep What time do you usually go to sleep? Arise: Do you have problems falling to sleep? How many times do you wake during the night: What times: Do you fall right back to sleep or lie awake for a while? How do you feel when you first wake up in the morning? Do you have vivid dreams? Do you have nightmares? Digestion How many meals do you eat per day? ---1 meal2 meal3 meal4 meal5 meal Describe your diet? What don’t you eat? Symptoms Do you experience any of the following problems? Stomach Ache Bloating Nausea Heartburn Vomiting Gas Blood in Stool Rectal itching or burning Incontinence Diarrhea Constipation Do you experience discomfort or fatigue after eating? Milk Wheat Corn Eggs Soy Products Sugar Peppers Others Do you have a history of blood sugar imbalances: NoYes If Yes Please Specify: ---DiabetesHypoglycemia FEMALE SECTION Hormonal Symptoms- Are you experiencing: Hot Flashes Yeast Infections Spotting between periods Herpes sores or warts Hemorrhaging Bladder infections Pain during intercourse Vaginal Infections Vaginal Discharge Sexually Transmitted Disease- If yes, Describe: Change in libido Increase Decrease Frequent Headaches When, how often, where: Other Symptoms Menstruation Cycle Have you had a hysterectomy? YesNo Date: Full or Partial (what parts do you have): Date of beginning of last period: Is your cycle regular? YesNo Does your period alternate months? YesNo How long is your average cycle? (eg 28 days) Is your period regular? YesNo How long is your period (eg 5 days) Which day is your heaviest flow? Are you taking birth control? YesNo If yes, list: Have you recently had a change in your flow? YesNo Describe: Any of the premenstrual symptoms which you experience: Cramps Bloating Breast Tenderness Weight Gain Mood Swings Irritability Depression Easily Upset Do you have a history of the following: Endometriosis Fibrocystic Breasts Ovarian Fibroids Ovarian Tumors Breast Cancer Pregnancy Are you pregnant? YesNo If yes, how long: Have you ever been pregnant? YesNo If yes, how many times: HRT Estradiol Dose Pregnenolone Dose Progesterone Dose Testosterone Dose Regarding your HRT: Want to stopWill Continue MALE SECTION Hormonal Symptoms (Sexual Dysfunction ) Do you experience: Bladder infections NoYes Libido Decrease NoYes Severe Sweating NoYes Discharge from penis NoYes Libido Increase NoYes Sexually transmitted disease NoYes Erectile Problems NoYes Pain on ejaculation NoYes Testicular enlargement NoYes Herpes or penile warts NoYes Prostate Cancer NoYes Testicular lumps NoYes Herpes sores or warts NoYes Prostatic hypertrophy NoYes Testicular pain NoYes Hot flashes/ flushing NoYes Prostatitis NoYes Testicular shrinkage NoYes Impotence NoYes
