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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

CBD American Shaman Medical Clinic Updated onpatient Reasons For Visit 5.29.2020 Medical Form

Preventive-Aging Medicine

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Published: May 29, 2020, 4:16 p.m.
Doctor: Dr. History Physical
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Sunnyvale, CA 94089

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