ALL INFORMATION IS STRICTLY CONFIDENTIAL


First Name *:
Last Name:
Date of Birth *:
Age :
Weight:
Height(feet):
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:

Bruise easily:
Puffy eyes:

Dark circles around eyes:

Brittle Nails:
Acne/itchy/blotchy skin:

Memory loss:

NoYes

Do you frequently feel:

NoYes

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?

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:


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