Medical Evaluation Form

MEDICAL EVALUATION FORM

Goal Important!
Through our desire to provide you with the most focused and personalied healthcare experience, we would like to understand the primary reason that has brought you to the clinic today. Please take a moment to identify which of the following you are hoping to achieve through you care at Maximum Performance Wellness Center.
(Please assign a numerical value from 1-7 to each goal in orderof importance, with "1" begin MOST important and "7" begin LEAST important.)

Improve Energy
Improve Well-Being
Weight Loss
Improved Sexual Function/Sex Drive
Improved Physical Stamina/Endurance/Strength
Management of a Chronic Illness (Heart Disease,Type II Diabetes, other)
Other Goal

MEDICAL EVALUATION FORM

PATIENT INFORMATION
How did you hear about our clinic?
Last Name
First Name
MI
Preferred Name
Address
City/Provice/Zip
Country
Date of Birth
Email
Home Phone
Mobile Phone
Preferred Method of contact
Profession
Nationality
May we send you a text message or email reminder the day before your appointment?
(We will not send you any other text message or emails without prior approval.)
YES NO


EMERGENCY CONTACT
Name
Home Phone
Mobile Phone
Relation to Patient

MEDICAL EVALUATION FORM

Health Questionnaire
How would you describe your general health?


MEDICAL HISTORY
Height : Maximum Weight :
Current Weight :
Date of Last Phisical Exam :
Date of Last Prostote Exam :


ALLERGIES/HYPERSENSITIVITIES:
Drugs :
Please indicate any serious conditions, illnesses or injuries, and any surgeries (including cosmetic),
or hospitalizations; along with approximate date :
Which medications, either by doctor's orders or over the counter, are you taking or have you taken in the past 6 month?
Antacids Cortisone/Prednisone
Antibiotics Diuretics
Anticonvulsants H2 Blockers/Ulcer medication
Antidepressants hormone replacement
Appetite Suppressants Laxatives
Birth control pills Pain Relievers
Blood pressure meds Sedatives
Chemotherapy Sleeping medications
Cholesteral-lowering medication Thyroid medication

MEDICAL EVALUATION FORM

Please list, by name, any prescription medications, over-the-counter medications, and all vitamins/supplements/herbs you ake regularly at this time. Include dosage if known. NOTE:PLEASE BRING EACH OF THESE WITH YOU TO YOUR FIRST OFFICE VISIT.
  
  
  
  
FAMILY HISTORY
Do you have a family history of any of the following diseases or conditions? When answering, include yourparents, brother/sisters, and grandparents, if know.
Disease/Condition
Alzheimer's
Anemia
Arthrtis
Asthma
Cancer
Diabetes
Epilepsy
Heart Disease
Hypertension
Kidney Disease
Mental Illness
Multiple Sclerosis
Parkinson's
Stroke

MEDICAL EVALUATION FORM