Medical history update returning patient - Cobb Wellness and Aesthetics

Name *

Date of Birth month-date-year *

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

More About You

Reason For Appointment-Please list your goals *

Please list all medications and the reason for taking:

What is your height and weight?

Please list all vitamins, herbs, supplements and why

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

Surgical History

General Medical Health Questions

Do you have a copy of any bloodwork done in the past 6 months?

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

If yes, how much a week

Are you interested in decreasing your alcohol intake?

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

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

Have you had any surgeries?

Yes
No

if yes, please list your surgeries and the year

Have you had any type of cancer?

Yes
No

Females Only

When was your last mammogram?

Was it normal?

When was your last Pap smear?

Was it normal?

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?

Any past history of abuse?

Do you feel supported by friends and family?

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?

Breakfast

Lunch

Dinner

Snacks

Food Diary – What did you eat 2 days ago?

Breakfast

Lunch

Dinner

Snack

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

Clear 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.