MEDICAL HISTORY

PERSONAL INFORMATION

Full Name

First NameLast Name

Birth Date

MonthDayYear

Age

Gender

Driver License

Upload a File

Scan and upload a copy of your driver license as an image or pdf.

CONTACT INFORMATION

Occupation

E-mail Address

example@domain.com

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mobile Phone Number

Area CodePhone Number

Home Phone Number

Area CodePhone Number

Work Phone

Area CodePhone Number

Fax Number

Area CodePhone Number

PHYSICAL EXAM

Have you had a physical exam in the past 12 months?

Physician Name

First NameLast Name

Physician Phone

Area CodePhone Number

Physician Fax

Area CodePhone Number

GENERAL HEALTH HISTORY

Primary Complaints

List the areas in which you desire the most immediate improvement.

Hospital Admissions & Surgeries

List all hospital admission and surgeries, the reason, and the outcome.

Current Medications & Supplements

List prescribed and over the counter medications and supplemements you take on a regular basis.

Allergies

Select all illnesses and symptoms you are experiencing currently or have experienced in the past.

FAMILY HISTORY

Select the illnesses that have affected your immediate family only.

DIABETIC QUESTIONNAIRE

Most Recent Hemoglobin A1C %

Date of Most Recent Hemoglobin A1C %

MonthDayYear

Insulin Dosing Protocol

NUTRITION ASSESSMENT

Height

Weight

Desired Weight

What are the most important reasons you want to lose weight?

What has stopped you from losing weight?

List any diets you have been on in the past two years and the benefits or problems you experienced.

Do you use weight loss supplements?

If yes, please explain.

List any food intolerances.

Do you consume caffeine?

Do you consume alcohol?

Do you use tobacco products (cigarrettes, cigars, chewing tobacco, etc.)?

PHYSICAL FITNESS

Use the following chart to rate the exercises you do on a weekly basis.

Type of Exercise

Frequency

Intensity

	1	2	3	4	5

1 is Light, 5 is Intense

Duration

Type of Exercise

Frequency

Intensity

	1	2	3	4	5

1 is Light, 5 is Intense

Duration

Type of Exercise

Frequency

Intensity

	1	2	3	4	5

1 is Light, 5 is Intense

Duration

Type of Exercise

Frequency

Intensity

	1	2	3	4	5

1 is Light, 5 is Intense

Duration

Type of Exercise

Frequency

Intensity

	1	2	3	4	5

1 is Light, 5 is Intense

Duration

COGNITIVE FUNCTION

Sometimes I forget what day of the week it is.

Sometimes when I’m looking for something I forget what it is.

It’s hard for me to add two-digit numbers mentally.

I frequently forget appointments.

Small problems upset me more than they once did.

It takes me longer to learn something than it used to.

I rarely feel energetic.

I find it difficult to multi-task.

My friends and family think I'm more forgetful now.

Sometimes I forget the names of my friends.

It's hard for me to concentrate for even an hour.

I often misplace my keys.

I frequently repeat myself.

Sometimes I get lost when driving somewhere I’ve been.

I often forget the point I’m trying to make.

To feel mentally sharp, I depend upon caffeine.

MEN: ANDROPAUSE ASSESSMENT

Fatigue, tiredness, loss of energy

	1	2	3	4	5

1 is None, 5 is Severe

Anxiety, nervousness

	1	2	3	4	5

1 is None, 5 is Severe

Irritability, anger, bad temper

	1	2	3	4	5

1 is None, 5 is Severe

Relationship problems with partner

	1	2	3	4	5

1 is None, 5 is Severe

Low libido

	1	2	3	4	5

1 is None, 5 is Severe

Erectile dysfunction during sex

	1	2	3	4	5

1 is None, 5 is Severe

Decreased morning erections

	1	2	3	4	5

1 is None, 5 is Severe

Decreased intensity of orgasms

	1	2	3	4	5

1 is None, 5 is Severe

Backache, joint pain, stiffness

	1	2	3	4	5

1 is None, 5 is Severe

Loss of fitness or ability to exercise

	1	2	3	4	5

1 is None, 5 is Severe

Memory loss, decreased ability to concentrate

	1	2	3	4	5

1 is None, 5 is Severe

Feeling over-stressed

	1	2	3	4	5

1 is None, 5 is Severe

WOMEN: MENOPAUSE ASSESSMENT

Are you currently pregnant?

How many pregnancies have you had?

List complications with pregnancies, if any.

Do you still have a menstrual cycle?

If irregular, please explain.

What was the first day of your last menstrual cycle?

MonthDayYear

What form of birth control do you use?

Have you had a hysterectomy?

If yes, please explain why and when this occurred.

Please rate the severity of the symptoms you are experiencing.

Acne

	1	2	3	4	5

1 is None, 5 is Severe

Anxiety

	1	2	3	4	5

1 is None, 5 is Severe

Arthritis

	1	2	3	4	5

1 is None, 5 is Severe

Bladder problems

	1	2	3	4	5

1 is None, 5 is Severe

Breast tenderness

	1	2	3	4	5

1 is None, 5 is Severe

Decreased sense of sexuality

	1	2	3	4	5

1 is None, 5 is Severe

Decreased sex drive

	1	2	3	4	5

1 is None, 5 is Severe

Depression

	1	2	3	4	5

1 is None, 5 is Severe

Difficulty reaching orgasm

	1	2	3	4	5

1 is None, 5 is Severe

Dry skin and/or hair

	1	2	3	4	5

1 is None, 5 is Severe

Facial hair growth

	1	2	3	4	5

1 is None, 5 is Severe

Fatigue

	1	2	3	4	5

1 is None, 5 is Severe

Fibrocystic breasts

	1	2	3	4	5

1 is None, 5 is Severe

Fibromyalgia

	1	2	3	4	5

1 is None, 5 is Severe

Food cravings

	1	2	3	4	5

1 is None, 5 is Severe

Increased breast size

	1	2	3	4	5

1 is None, 5 is Severe

Forgetfulness

	1	2	3	4	5

1 is None, 5 is Severe

Hair loss

	1	2	3	4	5

1 is None, 5 is Severe

Headaches

	1	2	3	4	5

1 is None, 5 is Severe

Heart palpitations

	1	2	3	4	5

1 is None, 5 is Severe

High blood pressure

	1	2	3	4	5

1 is None, 5 is Severe

Hot flashes

	1	2	3	4	5

1 is None, 5 is Severe

Insomnia

	1	2	3	4	5

1 is None, 5 is Severe

Irritability

	1	2	3	4	5

1 is None, 5 is Severe

Low blood pressure

	1	2	3	4	5

1 is None, 5 is Severe

Mood swings

	1	2	3	4	5

1 is None, 5 is Severe

Nipple tenderness

	1	2	3	4	5

1 is None, 5 is Severe

Osteoporosis

	1	2	3	4	5

1 is None, 5 is Severe

Sagging breasts

	1	2	3	4	5

1 is None, 5 is Severe

Temperature intolerance

	1	2	3	4	5

1 is None, 5 is Severe

Vaginal dryness

	1	2	3	4	5

1 is None, 5 is Severe

Water retention

	1	2	3	4	5

1 is None, 5 is Severe

Weight gain

	1	2	3	4	5

1 is None, 5 is Severe

Weight loss

	1	2	3	4	5

1 is None, 5 is Severe

HRT HISTORY

Have you previously used hormones?

If yes, please explain.

Which treatments are of interest to you?

What are you hoping to achieve through hormone replacement therapy?

PATIENT REFERRAL

Refer a friend or family member to Atlantic Rejuvenation and we will apply $100 towards your account for each referral.

Referral #1

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Referral #2

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Referral #3

First NameLast Name

Phone Number

Area CodePhone Number

E-mail