Health History Questionnaire
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Deepa B Verma, MD, AIHM 3165 N. McMullen Booth Rd, D-2 Clearwater, FL 33761 (p) 727.754.2936 (f) 727.754.2937
Health History Questionnaire
All material in this questionnaire is strictly confidential and will become part of your medical record
Today's Date:
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MM slash DD slash YYYY
Name
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First
Middle
Last
DOB:
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MM slash DD slash YYYY
Age:
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Gender:
*
Female
Male
Home Address:
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Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone:
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Cell Phone:
Work Phone:
E-Mail
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Preferred Daytime Contact Phone:
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Home
Cell
Work
Race/Ethicity:
Employer:
PCP Name & Phone Number:
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Names of Specialists (if any):
Date of Last Physical:
Referred By:
Main Reason For Visit:
Past & Present Medical Conditions and Family History:
Acid Reflux
Self History
Family History
Alcoholism
Self History
Family History
Allergies
Self History
Family History
Anemia
Self History
Family History
Anxiety
Self History
Family History
Arthritis
Self History
Family History
Asthma
Self History
Family History
ADD/ADHD
Self History
Family History
Bipolar Disease
Self History
Family History
Cancer & Type of
Self History
Family History
Cataracts
Self History
Family History
Clotting Disorders
Self History
Family History
Congestive Heart Failure
Self History
Family History
Constipation
Self History
Family History
Crohn's
Self History
Family History
Dementia
Self History
Family History
Depression
Self History
Family History
Diabetes & Type
Self History
Family History
Diarrhea
Self History
Family History
Dizziness
Self History
Family History
Drug Abuse
Self History
Family History
Eating Disorder
Self History
Family History
Eczema
Self History
Family History
Fibromaylagia
Self History
Family History
Glaucoma
Self History
Family History
Gluten Sensitivity
Self History
Family History
Gout
Self History
Family History
Gallbladder disease
Self History
Family History
Heart Attack/Angina
Self History
Family History
Heart Valve Disorder
Self History
Family History
High Blood Pressure
Self History
Family History
High Cholesterol
Self History
Family History
HIV
Self History
Family History
Hyperthyroidism
Self History
Family History
Hypothyroidism
Self History
Family History
Immune Problems
Self History
Family History
Infertility
Self History
Family History
Insomnia
Self History
Family History
Irregular Heartbeat
Self History
Family History
Kidney disease/stones
Self History
Family History
Liver Disease/Fatty Liver
Self History
Family History
Lyme Disease
Self History
Family History
Migraine Headaches
Self History
Family History
Multiple Sclerosis
Self History
Family History
Obesity
Self History
Family History
Osteoporosis
Self History
Family History
Peripheral Arterial Disease
Self History
Family History
Psoriasis
Self History
Family History
Schizophrenia
Self History
Family History
Seizures
Self History
Family History
Stroke
Self History
Family History
Ulcers
Self History
Family History
Where were you born?
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Do you travel internationally?
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How often do you travel internationally?
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When you travel, where do you go?
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Have you had
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Chicken Pox
Measles
Mumps
Polio
Rheumatic Fever
No
Are you adopted?
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Yes
No
Is your mother
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Alive
Deceased
Unknown
Age & Current Medical/Psych Problems
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Age at Death & Cause
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Is your father
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Alive
Deceased
Unknown
Age & Current Medical/Psych Problems
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Age at Death & Cause
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Do you have siblings?
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No
Yes
Unknown
Brother(s) (Full & Half), Age(s), Medical/Psych Problems
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Sister(s) (Full & Half), Age(s), Medical/Psych Problems
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Is your maternal grandmother (MGM) (Alive/Deceased?)
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Alive
Deceased
Unknown
Cause of Death, Age, Medical/Psych Problems
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Is your maternal grandfather (MGF) (Alive/Deceased?)
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Alive
Deceased
Unknown
Cause of Death, Age, Medical/Psych Problems
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Is your paternal grandmother (PGM) (Alive/Deceased?)
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Alive
Deceased
Unknown
Cause of Death, Age, Medical/Psych Problems
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Is your paternal grandfather (PGF) (Alive/Deceased?)
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Alive
Deceased
Unknown
Cause of Death, Age, Medical/Psych Problems
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Past Surgeries & Hospitalizations:
1. Name/Reason/Diagnosis
Year
2. Name/Reason/Diagnosis
Year
3. Name/Reason/Diagnosis
Year
4. Name/Reason/Diagnosis
Year
5. Name/Reason/Diagnosis
Year
6. Name/Reason/Diagnosis
Year
7. Name/Reason/Diagnosis
Year
8. Name/Reason/Diagnosis
Year
9. Name/Reason/Diagnosis
Year
10. Name/Reason/Diagnosis
Year
11. Name/Reason/Diagnosis
Year
12. Name/Reason/Diagnosis
Year
Current Height
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Current Weight
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Prescribed Pharmaceutical and/or Nutraceutical Medications & Dosages if Known:
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OTC Drugs/Vitamins/Supplements/Herbs & Dosages if Known:
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Known Drug Allergies/Sensitivities:
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Known Food Allergies/Sensitivities:
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Known Environmental Allergies:
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Lifestyle Questions:
Are you trying to lose weight
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No
Yes
If yes, how many pounds?
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Highest weight
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Lowest weight
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Are you following a diet
*
No
Yes
If yes, type
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Doctor Prescribed
Atkins
Mediterranean
South Beach
Raw Food
Vegan
The Zone
Vegetarian
Weight Watchers
NutriSystem
Jenny Craig
Macrobiotic
Cookie
Glycemic Index
Other
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How many BMs daily and is it formed/regular?
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Do you exercise
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No
Yes
If yes, what type of exercise?
How many times per week?
How many minutes per day?
Have you ever been a member at a gym?
Worked with personal trainer?
Do you drink alcohol
*
No
Yes
What is the frequency?
Are you dependent on alcohol?
If so, for how many months/years?
What is your preferred alcoholic beverage(s)?
Do you currently abuse recreational or prescription drugs
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No
Yes
For how long and what types?
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Do you smoke
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No, never
I used to for this many years
Yes, current use.
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Packs per day
*
Number of packs daily
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Since age
Have you ever considered a cosmetic procedure?
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I've Strongly Considered It
I've Thought About It But Not Sure
I've Never Considered It
If yes, which of the following procedure would be the most beneficial to your needs?
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Liposculpting
Purified Natural Fat Transfer to the Breasts
Purified Natural Fat Transfer to the Buttocks
Mini Tummy Tuck
Skin Tightening
Other
How many hours of sleep do you get?
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Is it refreshing/restorative?
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Do you take naps during the day
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No
Yes
Do you wake up in the middle of the night
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No
Yes
How many times and why?
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Have you ever been exposed to chemicals?
Do you drink coffee?
*
No
Yes
If yes to drinking coffee
Black Coffee
Cream Only
Sugar Only
Cream and Sugar
cups daily
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Do you drink tea?
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No
Yes
What types of tea?
*
What do you put in your tea?
*
Soda
*
No
Yes
cups daily
*
cups weekly
What type of soda do you drink?
Do you drink juice
*
No
Yes
cups daily and type(s)
*
Do you use sweeteners
*
No
Yes
I use this type
How many glasses of water do you drink daily?
Type of water?
What types of cravings do you have
Sweet
Salty
Fatty
Carbs
What are your main sources of protein?
How many fruits & vegetables do you eat daily?
Types?
How often do you eat fast food or at a restaurant?
How many meals do you eat daily?
Do you eat breakfast
*
No
Yes
If yes, what?
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Describe your lunch
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Describe your dinner
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Do you snack between meals?
*
No
Yes
If yes, what?
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Have you ever seen a therapist or a life coach?
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At what age did you feel your best? Or do you think it is yet to come?
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What do you enjoy most in life?
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What are you most scared of in life?
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What are your pet peeves?
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What are your hobbies?
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Are you religious or spiritual?
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Do you enjoy your job?
*
Do you feel fulfilled in life?
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What are your life stressors?
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What is your sexual orientation?
*
Have you ever been abused (physically, emotionally, sexually)?
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If you are in a relationship, is it healthy?
*
Do you have emotional support?
*
Who is in your household?
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Do you have pets?
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How would you describe your personality?
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Name 3 personal strengths
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Name 3 personal weaknesses
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What goals do you want to achieve in life?
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Have you ever considered aesthetic treatments for anti-aging?
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Whether you are male or female, would you consider organic skin care?
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Are you interested in laser skin resurfacing or microneedling?
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For women, would you consider vaginal rejuvenation to improve intimacy and incontinence?
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Do you feel anti-aging and aesthetic treatments are important to feel refreshed and rejuvenated?
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Have you ever considered stem cells or fillers or Botox/Xeomin to maintain youth or treat medical conditions?
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Birth and Childhood Questions
How was your Mother's pregnancy with you?
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Was it a healthy pregnancy?
*
No
Yes
Did she take any pharma meds?
*
No
Yes
Did she drink alcohol?
*
No
Yes
Did she do drugs?
*
No
Yes
Was she depressed?
*
No
Yes
How old was she when she was pregnant with you?
*
Were you born full-term or pre-term?
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full-term
pre-term
Were you born vaginally or via c-section?
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vaginally
c-section
Were you breast-fed or formula-fed or both?
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breast-fed
formula-fed
both
How was your childhood?: (Select all that apply)
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I was sick a lot
I was seldom sick
I was hospitalized
Overall, I was healthy
I took a lot of antibiotics
I seldom took antibiotics
I took a lot of steroids such as prednisone
Describe any major incidents or illness you had.
*
FOR FEMALES
How many times have you been pregnant total?
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Living children
*
Abortions
*
Miscarriages
*
Pre-term
*
Full-term
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Stillborn
*
Ectopic
*
# C-sections
*
# of Vaginal births
*
Adopted children
*
Have you ever been a surrogate?
*
Have you tried IVF?
*
Was it successful?
*
Have you had a mammogram
*
No
Yes
Have you ever had a breast lump
*
No
Yes
Was the lump benign or malignant?
*
Age of first period
*
Date of your last period
*
Regular
Irregular
Heavy bleeding
No
Yes
Painful periods
*
No
Yes
# Days period lasts
*
Are you sexually active
*
No
Yes
Are you satisfied
*
No
Yes
Vaginal dryness
*
No
Yes
Loss of libido
*
No
Yes
Loss of orgasm
*
No
Yes
Hot flashes/Night sweats
*
No
Yes
Urine leakage
*
No
Yes
Hair loss
*
No
Yes
Breast tenderness
*
No
Yes
Mood swings
*
No
Yes
Dry skin/wrinkles
*
No
Yes
Adult Acne
*
No
Yes
Food cravings
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No
Yes
Sleep disturbance
*
No
Yes
Fatigue
*
No
Yes
Wear sunscreen/SPF products
*
No
Yes
FOR MALES
Loss of aggressiveness
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No
Yes
Loss of libido
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No
Yes
Loss of confidence
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No
Yes
Difficulty achieving erection
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No
Yes
Difficulty maintaining erection
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No
Yes
Premature ejaculations
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No
Yes
Performance anxiety
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No
Yes
Loss of orgasm
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No
Yes
Loss of masculinity
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No
Yes
Irritability
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No
Yes
Mood swings
*
No
Yes
Memory loss
*
No
Yes
Sleep disturbance
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No
Yes
Breast enlargement/Tenderness
*
No
Yes
Abnormal penile discharge
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No
Yes
Prostate problems
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No
Yes
Skin/Hair problems
*
No
Yes
Fatigue
*
No
Yes
Increased abdominal girth
*
No
Yes
Loss of muscle tone
*
No
Yes
THANK YOU! BE HEALTHY. BE HAPPY. BE AWESOME
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