cobb medical history - Cobb Wellness and Aesthetics

Name *

Date of Birth *

Phone Number *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

In case of Emergency name and number

Preferred pharmacy name and number

Financial Agreement

I claim full financial responsibility for services at Cobb Wellness & Aesthetics and understand that fill payment is required at the time of service.

Signature *

Would you like to know more about our Aesthetics side? If so, what are you interested in?

More About You

What is your height and weight?

Reason For Appointment

What would you like to accomplish from your visits?

Please list all medications and the reason for taking:

Please list all vitamins, herbs, supplements and why

Fo you have any allergies to medications, foods, or supplements? If so, please list

Surgical History

Have you had an EKG? If so, when? Was it normal?

Have you ever as a stress test? If so, when? Was it normal?

Have you had a colonoscopy? If so, when? Was it normal?

General Medical Health Questions

If you want to lose weight, how much do you want to lose?

Please list any medical problems:

Are you under the care of another physician for any medical condistions?

Yes
No

If so, what for?

Do you drink alcohol?

Yes
No

Do you smoke?

Yes
No

Please check all the apply

If so, please explain

Are you having any GI symptoms – bloating, gas, indigestion?

Yes
No

If other, please explain

Check All That Apply

Beta-Blockers
Diuretics
Steroids

I am:

Now Overweight
Less Then 20 lbs Overweight
20 – 40 lbs Overweight
40 lbs or More Overweight

Check all that apply

Review of Your System

General

Head

Headaches
Dizziness
Hearing difficulity
Sinus trouble

Heart

Chest pain
Shortness of breath
Palpitations
Heart murmue

Lungs

Wheezing
Chronic Cough
Unable to take deep breaths
Coughing up blood

GI Concerns

Do you have daily bowel movements? *

Yes
No

If no, how often do you have bowel movements?

Breast

Pain
Discharge
Lumps
Bleeding

Bladder

Extremities

Calf pain
Legs swelling
Cold hands or feet
Tingling in arms, hands, legs, or feet

Family History

Females Only

Last breast exam:

Last mammogram and your result:

Last Pap and result:

Pregnancy: Dates, how far along did you carry, sex of child, weight and any problems:

Dates of your last two cycles:

Are you perimenopausal?

Have you been through menopause? If so, how long did you go through it?

Do you have any sexual concerns? If so, what are they?

Males Only

When was your last physical?

Have you has a prostate exam?

Have you had your PSA tested? If so, what was your last level?

Do you exam your testicles? If so, have you ever had a concern?

Social History

Are you happy with you life?

Do you feel supported by friends and family?

Any past history of abuse?

How would you rate your stress in life? High, medium, or low:

How do you copy with stress in your life?

How many hours do you sleep at night?

When you wake, do you feel rested?

Do you exercise? If so, what do you do and for how long?

Do you have any dietary restrictions?

Are you sensitive to any foods?

Do you feel like you have a healthy diet?

Do you crave sugar or salt?

Do you eat meat/protein everyday?

Do you eat veggies everyday?

Food Diary – What did you eat yesterday?

Breakfast

Lunch

Dinner

Snacks

Food Diary – What did you eat 2 days ago?

Breakfast

Lunch

Dinner

Snack

Patient Privacy Policy

I have been informed that a copy of Cobb Wellness & Aesthetics Notice of Privacy Practices, is posted in the waiting room area. A copy of this will be furnished to me upon my request.

Signature

HIPPA is an acronym for the Health Insurance Portability & Accountability Act of 1996. Of significant concern to healthcare originations is the Administrative Simplication section of the Act, which requires healthcare organizations to comply with specific rules regarding: unique identifiers for health plans, providers, individuals, employers, healthcare transaction & code sets for transmitting data electronically, privacy regulations over disclosure and use of health information. It is our policy to NOT release confidential and/or unauthorized information except appointment confirmation by phone, email, or text.

Confirmation

Do you affirm that you have answered all questions truthfully and to the best of your knowledge? *

Yes