First Name *

Last Name *

Date of birth *

Gender

Height (inches)

Weight (lbs)

Phone *

Email *

List Occupation

How long?

Physician Phone

Physician Address

Date of last exam

Last Prostate examination

Last Mammogram

Last Pap Smear

Last Colonoscopy

Most recent blood work performed

Diagnosed History of Disease

Endocrine Related Medical History

Immune System Related Medical History

Are you currently under the care of a physician or health professional for a medical/health condition?

Any history of cancer?

Women's History

Menopausal patients

Are you pregnant?

First day of last menstrual cycle

Are you concerned with loss of muscle mass, tone, or strength?

Date of last mammogram

Results of last mammogram

Date of last pelvic ultrasound

Results of last pelvic ultrasound

Do you perform monthly self-breast exams?

Are you currently taking or have you in the past taken hormones or oral contraceptives?

Have you ever had any problems or concerns taking hormone replacement therapy?

How many pregnancies have you had?

How many children?

Have you had a hysterectomy?

Have you had any menstrual irregularities?

Has your abdominal girth and weight been increasing?

My health is

Do you feel stress?

Exercise Habits

No special exercise habits

I routinely exercise

Do you do cardio exercise?

Yes

No

Do you do strength training?

Yes

No

Do you do stretch/yoga?

Yes

No

Signature Date *