Medical History Form
Thank you for taking some time to inform us about your health history and goals prior to your initial consult.
First Name
Last Name
Date of Birth
Do you have any of the following conditions?
Type 1 Diabetes
Type 2 Diabetes
Pre-Diabetes
High Cholesterol/Lipids
Hypertension/High Blood Pressure
Arthritis
Asthma
Cancer
Chronic Kidney Disease/End Stage Renal Disease
COPD/Emphysema
Heart Disease
Hepatitis/Cirrhosis
HIV
Learning Disability
Sickle Cell Disease
Stroke/CVA/TIA
Transplant
Gastric Bypass Surgery
Other
What are your current prescribed medications?
What supplements do you take? Vitamins/Minerals
What is your Height?
What is your Weight?
Have you been hospitalized or visited the ER in the past 6 months?
What is your Primary Care Physician's name and phone number?
When was the last time you saw your doctor?
When were your last medical labs drawn? And were any abnormal?
If Diabetic, what was your most recent A1c and date drawn?
What are your main health goals?
Weight Control
Lower A1c/Blood Sugars
Lower lipid levels
Lower blood pressure
Lower risk for chronic illness
Optimize nutrition
Boost chances of getting pregnant/healthy pregnancy
Look better
Feel better
Sleep better
Have more energy
Be less out of breath
Walk and move with ease
Specific nutrition related condition
What is your "why"? Thank you for sharing some reasons you want to take charge of your health. Of all the reasons, think about the three that are most important to you. Deciding on your biggest “why” will help you stay strong about your health goals.
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