|
REASON FOR VISIT TODAY
|
|
|
Weight Loss/Maintenance
|
|
|
Weight Loss Program
|
|
|
Medical Weight Loss Program
|
Weight Loss
• • •
|
|
Surgery Pre-op and Post-op
|
General and Weight Loss surgery
• • •
|
|
Lap Band Maintenance
|
Lap Band Concerns
• • •
|
|
Weight Loss Review form
|
|
|
Current clothing size
|
clothing fit
• • •
|
|
Last breakfast
|
Last Lunch
|
|
Last Dinner
|
Liquid calories/drinks
|
|
Snacks in last 24 hours
|
|
|
Have portion sizes increased or decreased since your last visit?
|
|
|
Nutrition Obstacles
• • •
|
Obstacles other
|
|
Medication use
• • •
|
Medication use comments
|
|
Medication side effects
• • •
|
Medication Side Effect comment
|
|
Exercise
• • •
|
Exercise Duration average per session
|
|
Exercise Frequency per week average
|
Exercise obstacles
• • •
|
|
Exercise comments
|
|
|
Hormone Treatment
|
|
|
HORMONE TREATMENT WOMEN
|
|
|
Women Hormone Reasons
• • •
|
|
|
Low Estrogen Symptoms - Female
|
|
|
Hot Flashes
|
Hot Flash Severity
|
|
Hot Flashes Day time_________# per week
|
Hot Flashes Night time_________# per week
|
|
Night Sweats
|
|
|
Night sweats severity
|
Night Sweats _________# per week
|
|
Night sweats - areas
• • •
|
|
|
Genital/urinary
|
|
|
Vaginal dryness
|
Intercourse/other symptoms
• • •
|
|
Incontinence
|
|
|
Estrogen Dominant Symptoms - Female
|
|
|
Menstrual symptoms
|
|
|
Irregular periods
|
Menstrual Frequency
|
|
Menstrual Flow
|
Menstrual Pain/cramps
|
|
Uterine fibroids
|
Water retention
|
|
Breasts
|
|
|
Tender breasts
|
Fibrocystic breasts
|
|
Thinking and Mood
|
|
|
Increased forgetfulness
|
Foggy thinking
|
|
Tearfulness
|
Depressed
|
|
Mood swings
|
|
|
Adrenal Function - Female
|
|
|
Stress and Energy
|
|
|
Levels of stress
|
Morning fatigue
|
|
Afternoon Fatigue
|
Evening fatigue
|
|
Difficulty sleeping
|
Decreased stamina
|
|
Mood
|
|
|
Anxious
|
Irritable
|
|
Nervous
|
|
|
Adrenal other symptoms
|
|
|
Ringing in ears
|
Generalized aches and pain - fibromyalgia symptoms
|
|
Environmental and Food Allergies severity
|
Headaches
|
|
Sugar cravings
|
Dizzy spells
|
|
Thyroid Function - Female
|
|
|
Cold body temperature
|
Goiter (Enlarged Thyroid)
|
|
Hoarseness
|
Hair dry or brittle
|
|
Nails breaking or brittle
|
Constipation
|
|
Slow pulse rate
|
Rapid Heartbeat/Heart palpations
|
|
Metabolic Syndrome/High Androgen - Female
|
|
|
Infertility problems
|
Acne
|
|
Increased facial hair/body hair
|
Scalp hair loss
|
|
Weight gain-hips
|
Weight gain-waist
|
|
High cholesterol
|
Elevated triglycerides
|
|
Low Androgen/Other - Female
|
|
|
Decreased libido
|
Decreased muscle size
|
|
Thinning skin
|
Rapid aging
|
|
Aches and pains
|
Bone loss
|
|
Comments
|
|
|
HORMONE TREATMENT MEN
|
|
|
Men reasons for seeking hormone treatment
• • •
|
Men Hormone symptoms onset and severity
• • •
|
|
Estrogen Dominant - Male
|
|
|
Prostate problems
|
|
|
Decreased urine flow
|
Increased urinary urge
|
|
Metabolic Syndrome/Low Androgens - Male
|
|
|
Weight gain - chest/hips
|
Weight gain - waist
|
|
Decreased libido
|
Decreased erection
|
|
Ringing in ears
|
High cholesterol
|
|
Elevated triglycerides
|
Hot flashes
|
|
Night sweats
|
Decreased mental sharpness
|
|
Increased forgetfulness
|
Decreased muscle size
|
|
Decreased flexibility
|
Sore muscles
|
|
Increased joint pain
|
Neck or back pain
|
|
Bone loss
|
Rapid aging
|
|
Thinning skin
|
Decreased stamina
|
|
Burned out feeling
|
Infertility problems
|
|
Stress
|
Morning fatigue
|
|
Afternoon fatigue
|
Evening fatigue
|
|
Difficulty sleeping
|
Apathy
|
|
Depressed
|
Foggy thinking
|
|
Anxious
|
|
|
Adrenal - Male
|
|
|
Irritable
|
Nervous
|
|
Headaches
|
Sugar cravings
|
|
Dizzy spells
|
Allergies
|
|
Thyroid/Other - Male
|
|
|
Cold body temperature
|
Goiter (Enlarged Thyroid Gland)
|
|
Hoarseness
|
Hair dry or brittle
|
|
Constipation
|
Slow pulse rate
|
|
Rapid heartbeat/Heart palpations
|
Thyroid Related symptom comments
|
|
PRIMARY CARE - GENERAL MEDICAL CLINIC
|
|
|
Primary Care Wellness Visit
|
Wellness - select all that apply
• • •
|
|
Primary Care Illness
|
Illness - select all that apply
• • •
|
|
IN-OFFICE PROCEDURES
|
|
|
Pellet implant
|
Pellet Implantation
• • •
|
|
Stem Cell/Biologics - Medical
|
Biologic - select all that apply
• • •
|
|
Laboratory/Phlebotomy
|
Lab/Phlebotomy - select all that apply
• • •
|
|
Minor office surgery
|
Minor Office Surgery
• • •
|
|
CBD SPECIALTY CLINIC
|
|
|
CBD Consultation or Follow up
|
CBD
• • •
|
|
MED SPA/AESTHETICS
|
|
|
MEDICAL SPA SERVICES
|
|
|
What Procedures Interest You?
• • •
|
What would you like to achieve from your treatments
|
|
Medical conditions and aesthetic procedures you may have had in the past. you have or have had in the past
• • •
|
What areas of concern do you have regarding your skin? (check all that apply)
• • •
|
|
Which describes you when exposed to sun for 30 minutes with no SPF
|
Skin Conditions additional information
|
|
Previous facial
|
Last Facial
|
|
Previous Body Spa Treatments
|
Previous Body Spa Treatments
|
|
Previous skin peel procedures
|
How long ago was your latest skin peel procedure?
• • •
|
|
|
Skin Peel Type - select all as needed
• • •
|
|
Current Skin Care Products
|
Skin Care Products
• • •
|
|
Do you use self-tanning products?
|
When was your last application of self-tannning products?
|
|
Tanning bed or intentional outdoors tanning in the last 2 weeks.
|
Intentional tanning (tanning bed or outdoors)
• • •
|
|
Methods of hair removal
|
Hair removal methods
• • •
|
|
Any infections in the last month?
|
Recent infections
• • •
|
|
|
Recent infections additional information
|
|
Have you had any dental procedures in the last 4 weeks?
|
|
|
Allergies - Must review for all visits please.
• • •
|
Please describe the type of allergic reaction
|
|
What SPF do you use and how often?
• • •
|
Use a higher SPF on my face than my body
|
|
Cosmetic or medical injections in the last 2 weeks
|
Injections in the last 2 weeks.
• • •
|
|
Female Clients Only - aesthetics
|
|
|
Pregnancy/Contraception
|
|
|
Using Contraceptives
|
Contraceptive methods
• • •
|
|
Most recent change in contraceptive
|
Changes in contraception
|
|
Currently pregnant or attempting to become pregnant
|
Lactating or Breastfeeding
|
|
Contraception/Pregnancy/Lactation additional
|
|
|
Menopause
|
Are you undergoing hormone replacement therapy?
|
|
Male Clients Only
|
|
|
What is your current shaving system?
• • •
|
Do you experience irritation from shaving?
|
|
Ingrown hairs?
|
|
|
IV/IM Nutrition
|
|
|
Intravenous or Intramuscular Nutrition
|
IV or IM Nutrition
• • •
|
|
REVIEW OF SYSTEMS - ALL PATIENTS/CLIENTS
|
|
|
No physical/mental symptoms or problems
|
I have physical/mental symptoms or problems to report
|
|
Pain Assessment
|
|
|
Location of pain or discomfort
|
Where is the pain located
• • •
|
|
location additional
|
|
|
Type of pain or discomfort
|
Quality
• • •
|
|
quality additional
|
|
|
Severity of pain or discomfort
|
Level of discomfort
• • •
|
|
severity additional
|
|
|
How often does this pain occur?
|
How often
• • •
|
|
timing additional
|
|
|
When did this problem start?
|
Onset and Duration
• • •
|
|
onset additional
|
|
|
How did this start?
|
Brief explanation of possible cause
|
|
Is this getting better or worse
|
Course
• • •
|
|
What makes this worse?
|
aggravating factors
• • •
|
|
Aggravating additional
|
|
|
What makes this better?
|
Alleviating Factors
• • •
|
|
Alleviating additional
|
|
|
General [-]
|
General
• • •
|
|
General Comments
|
|
|
Skin [-]
|
Skin
• • •
|
|
Skin Comments
|
|
|
Head, Eyes, Ears, Nose, Throat
|
HEENT
• • •
|
|
HEENT Comments
|
|
|
Neck [-]
|
Neck
• • •
|
|
Neck Comments
|
|
|
Breasts [-]
|
Breasts
• • •
|
|
Breasts Comments
|
|
|
Heart [-]
|
Cardiovascular
• • •
|
|
CV Comments
|
|
|
Breathing/Lungs[-]
|
Respiratory
• • •
|
|
Resp Comments
|
|
|
Stomach/digestion [-]
|
GI
• • •
|
|
GI Comments
|
|
|
Urinary [-]
|
Urinary
• • •
|
|
Urinary Comments
|
|
|
Genital (Male) [-]
|
Genital (Male)
• • •
|
|
Genital (Male) Comments
|
|
|
Genital (Female)
|
Genital (Female)
• • •
|
|
Genital (Female) Comments
|
|
|
Circulation of legs and arms:
|
Periph. Vasc.
• • •
|
|
Periph. Vasc. Comments
|
|
|
Muscles and Bones [-]
|
MSK
• • •
|
|
MSK Comments
|
|
|
Nervous System[-]
|
Neurological
• • •
|
|
Neuro Comments
|
|
|
Endocrine (Diabetes, thyroid, adrenal glands) [-]
|
Endocrine
• • •
|
|
Endo Comments
|
|
|
Mental Health [-]
|
Mental Health
• • •
|
|
Mental health additional comments
|
|
|
LAST COMPLETE PHYSICAL AND PCP
|
|
|
Date of last complete physical exam
|
|
|
Primary Care Provider/Family Doctor
|
PCP Contact Information
|
|
PERSONAL MEDICAL AND SURGICAL HISTORY
|
|
|
No new or updated medical or surgical history
|
New Medical/Surgical History
|
|
Medical /Surgical History
|
|
|
Past Medical History (age 13 and older)
• • •
|
Past Medical History additional
|
|
Surgeries
|
|
|
Past Surgical History
• • •
|
Past Surgical History comments
|
|
Childhood Illness or injuries
|
|
|
Childhood illnesses
• • •
|
Childhood Illness Comments
|
|
Immunizations
|
|
|
Immunizations
• • •
|
Immunization Comments
|
|
FAMILY MEDICAL HISTORY
|
|
|
No new family history to report or update
|
New family history to report or update
|
|
Father
|
|
|
Father
• • •
|
Father Comments
|
|
Mother
|
|
|
Mother's
• • •
|
Mother Comments
|
|
Siblings
|
|
|
Sibling(s)'
• • •
|
Sibling Comments
|
|
Grandparents
|
|
|
Grandparent's
• • •
|
Grandparent Comments
|
|
Children
|
|
|
Children(s)'
• • •
|
Children comments
|
|
SOCIAL HISTORY
|
|
|
No updates to social history
|
New social history
|
|
Marital Status
• • •
|
Environmental risks
• • •
|
|
Living Arrangements
• • •
|
|
|
Sexual Hx
|
|
|
Occupation
|
|
|
Substance Use
|
|
|
Coffee, Alcohol, Substances - Please review each visit
|
|
|
Caffeine use
• • •
|
|
|
Alcohol Use
• • •
|
|
|
Other Substances
• • •
|
Comment on substances
|
