Home
About
Services
Specials
Testimonials
Shop
- Hair Restoration
- Cart
Contact Us

Home
About
Services
Specials
Testimonials
Shop
- Hair Restoration
- Cart
Contact Us

Medical Health Questionnaire

Reason(Required)

New Patient

Name Change

Address Change

Insurance Change

ALL SECTIONS MUST BE COMPLETED FOR ALL PATIENTS:

Patient Name:(Required)

First Middle Initial Last

Date of Birth:(Required)

MM slash DD slash YYYY

Age:(Required)

Sex:(Required)

Male

Female

Mailing Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone:(Required)

Work Phone:

Cell Phone:

Your Email Address(Required)

Emergency Contact Name & Phone:(Required)

Primary Care Physician:(Required)

Referred by:(Required)

Reason For Visit?(Required)

How Did You Hear About Us?(Required)

Occupation:(Required)

Hours worked per week?(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

Separated

Physical Activity

Type

Duration

Intensity

(You can add more lines if you want)

Sleep:

How many hours per night do you sleep?(Required)

Do you wake up often?(Required)

Yes

No

How many times do you wake up per night?(Required)

Reason for waking?(Required)

Stress:

Do you experience an unusual amount of stress on a daily basis?(Required)

Methods used to relieve stress?(Required)

Weight History:

Height:(Required)

Current Weight:(Required)

Highest Weight:(Required)

Ideal Weight:(Required)

Family Medical History:(Required)

High Blood Pressure

Heart Attack

Stroke

Blood Clots

Bleeding

Tendencies

Diabetes

Glaucoma

Muscular Degeneration

Osteoporosis

Breast Cancer

Colorectal cancer

Thyroid Disorder

Depression

Bipolar

Manic Depressive

Alcohol Abuse

Substance Abuse

Dementia or Alzheimer’s Disease Celiac

None of the above

(Click all that apply)

Have you had any surgeries or hospitalizations?(Required)

Yes

No

Please list any surgeries or hospitalizations(Required)

Year

Reason

(You can add more lines If necessary)

Have you had any major illnesses or injuries?(Required)

Yes

No

List major illnesses or injuries:(Required)

Year

Reason

(You can add more lines If necessary)

Personal Medical History(Required)

Asthma

Emphysema

Pulmonary

Emboli

Arthritis

Osteoporosis

Back or Spine Problems

Carpal Tunnel

Depression

Anxiety

Schizophrenia

ADHD Bipolar

Substance Abuse Alcoholism

Kidney Stones

Impotence

Infertility

Menopause

Fibroids

Ovarian Cyst

Polycystic

Ovarian Syndrome

Endometriosis

Ulcers

Malabsorption

Diverticulosis

Hepatitis

Liver Disease

Lactose Intolerance

Heart Attack

Angina

Arrhythmia

High Blood Pressure

Heart Murmur

Glaucoma Epstein-Barr Chronic Fatigue

Seizures

Headaches

Migraines

Stroke

None Of The Above

(Click all that apply)

Do you have, or have you had, cancer?(Required)

Yes

No

Type(Required)

When(Required)

Please list any other medical conditions that you have been treated for, or are currently being treated for that are not listed above

Social History:

Do you smoke?(Required)

Yes

No

What type of smoke:(Required)

How much do you smoke?(Required)

Do you want to quit?(Required)

Do you drink alcohol?(Required)

Yes

No

How many drinks per week?(Required)

What do you drink?(Required)

Do you drink caffeine products (coffee, tea, energy drinks,soda)?(Required)

Yes

No

How many per day?(Required)

Do you know the date of your last physical exam?

Yes

No

What was the date of last physical exam?(Required)

MM slash DD slash YYYY

Date of last PSA or prostate exam?

MM slash DD slash YYYY

Have you had a vasectomy?(Required)

Yes

No

Date of last pap smear/pelvic exam?

MM slash DD slash YYYY

Date of last mammogram?(Required)

MM slash DD slash YYYY

Have you had a hysterectomy?(Required)

Yes

No

Are you taking any prescription or non-prescription medications, or nutritional supplements?

Yes

No

Please list all prescription and non-prescription medications and nutritional supplements:(Required)

Name

Dosage

Frequency

(You can add more lines If necessary)

Allergies:(Required)

Typical daily food intake:

Breakfast:

Weekdays

Weekends

Morning Snack:

Weekdays

Weekends

Lunch:

Weekdays

Weekends

Afternoon Snack:

Weekdays

Weekends

Dinner:

Weekdays

Weekends

Evening Snack:

Weekdays

Weekends

Midnight Snack:

Weekdays

Weekends

Hormone Questionnaire For Women

Night Sweats :(Required)

None

Mild

Moderate

Severe

Vaginal Dryness(Required)

None

Mild

Moderate

Severe

Incontinence(Required)

None

Mild

Moderate

Severe

Bleeding Changes(Required)

None

Mild

Moderate

Severe

Uterine Fibroids(Required)

None

Mild

Moderate

Severe

Water Retention(Required)

None

Mild

Moderate

Severe

Breast tenderness(Required)

None

Mild

Moderate

Severe

Fibrocystic Breast(Required)

None

Mild

Moderate

Severe

Increased Forgetfulness(Required)

None

Mild

Moderate

Severe

Foggy Thinking(Required)

None

Mild

Moderate

Severe

Tearful(Required)

None

Mild

Moderate

Severe

Depressed(Required)

None

Mild

Moderate

Severe

Mood Swings(Required)

None

Mild

Moderate

Severe

Difficulty Sleeping(Required)

None

Mild

Moderate

Severe

Decreased Stamina(Required)

None

Mild

Moderate

Severe

Anxious(Required)

None

Mild

Moderate

Severe

Irritable(Required)

None

Mild

Moderate

Severe

Nervous(Required)

None

Mild

Moderate

Severe

Fibromyalgia(Required)

None

Mild

Moderate

Severe

Allergies(Required)

None

Mild

Moderate

Severe

Headache(Required)

None

Mild

Moderate

Severe

Sugar Cravings(Required)

None

Mild

Moderate

Severe

Dizzy Spells(Required)

None

Mild

Moderate

Severe

Cold Body Temperature(Required)

None

Mild

Moderate

Severe

Goiter(Required)

None

Mild

Moderate

Severe

Hoarseness(Required)

None

Mild

Moderate

Severe

Dry and Brittle Hair(Required)

None

Mild

Moderate

Severe

Nails Breaking and Brittle(Required)

None

Mild

Moderate

Severe

Constipation(Required)

None

Mild

Moderate

Severe

Slow Pulse Rate(Required)

None

Mild

Moderate

Severe

Rapid Heart(Required)

None

Mild

Moderate

Severe

Heart Palpitations(Required)

None

Mild

Moderate

Severe

Infertility(Required)

None

Mild

Moderate

Severe

Acne(Required)

None

Mild

Moderate

Severe

Increased Facial/Body Hair(Required)

None

Mild

Moderate

Severe

Scalp Hair Loss(Required)

None

Mild

Moderate

Severe

Weight Gain On Hips(Required)

None

Mild

Moderate

Severe

Weight Gain Around Waist(Required)

None

Mild

Moderate

Severe

High Cholesterol(Required)

None

Mild

Moderate

Severe

Elevated Triglycerides(Required)

None

Mild

Moderate

Severe

Decreased Libido(Required)

None

Mild

Moderate

Severe

Decreased Muscle Size(Required)

None

Mild

Moderate

Severe

Thinning Skin(Required)

None

Mild

Moderate

Severe

Ringing in Ears(Required)

None

Mild

Moderate

Severe

Rapid Aging(Required)

None

Mild

Moderate

Severe

Aches and Pains(Required)

None

Mild

Moderate

Severe

Bone Loss(Required)

None

Mild

Moderate

Severe

Decreased Urine Flow(Required)

None

Mild

Moderate

Severe

Decreased Urinary Urge(Required)

None

Mild

Moderate

Severe

Hormone Questionnaire For Men

Prostate Problems(Required)

None

Mild

Moderate

Severe

Weight Gain On Chest/Hips(Required)

None

Mild

Moderate

Severe

Weight Gain Around Waist(Required)

None

Mild

Moderate

Severe

Decreased Libido(Required)

None

Mild

Moderate

Severe

Low Androgens(Required)

None

Mild

Moderate

Severe

Decreased Erections(Required)

None

Mild

Moderate

Severe

Ringing in Ears(Required)

None

Mild

Moderate

Severe

High Cholesterol(Required)

None

Mild

Moderate

Severe

Elevated Triglycerides(Required)

None

Mild

Moderate

Severe

Hot Flashes(Required)

None

Mild

Moderate

Severe

Night Sweats(Required)

None

Mild

Moderate

Severe

Decreased Mental Sharpness(Required)

None

Mild

Moderate

Severe

Increased Forgetfulness(Required)

None

Mild

Moderate

Severe

Decreased Muscle Size(Required)

None

Mild

Moderate

Severe

Decreased Flexibility(Required)

None

Mild

Moderate

Severe

Sore Muscles(Required)

None

Mild

Moderate

Severe

Increased Joint Pain(Required)

None

Mild

Moderate

Severe

Bone Loss(Required)

None

Mild

Moderate

Severe

Rapid Aging(Required)

None

Mild

Moderate

Severe

Thinning Skin(Required)

None

Mild

Moderate

Severe

Decreased Stamina(Required)

None

Mild

Moderate

Severe

Burned Out Feeling(Required)

None

Mild

Moderate

Severe

Stress(Required)

None

Mild

Moderate

Severe

Morning Fatigue(Required)

None

Mild

Moderate

Severe

Evening Fatigue(Required)

None

Mild

Moderate

Severe

Difficulty Sleeping(Required)

None

Mild

Moderate

Severe

Apathy(Required)

None

Mild

Moderate

Severe

Depression(Required)

None

Mild

Moderate

Severe

Mental Fatigue(Required)

None

Mild

Moderate

Severe

Anxiousness(Required)

None

Mild

Moderate

Severe

Irritability(Required)

None

Mild

Moderate

Severe

Nervousness(Required)

None

Mild

Moderate

Severe

Headaches(Required)

None

Mild

Moderate

Severe

Sugar Cravings(Required)

None

Mild

Moderate

Severe

Dizzy Spells(Required)

None

Mild

Moderate

Severe

Cool Body Temperature(Required)

None

Mild

Moderate

Severe

Goiter(Required)

None

Mild

Moderate

Severe

Hoarseness(Required)

None

Mild

Moderate

Severe

Dry or Brittle Hair(Required)

None

Mild

Moderate

Severe

Constipation(Required)

None

Mild

Moderate

Severe

Slow Pulse Rate(Required)

None

Mild

Moderate

Severe

Rapid Heart Rate(Required)

None

Mild

Moderate

Severe

Heart Palpitations(Required)

None

Mild

Moderate

Severe

Infertility Problems(Required)

None

Mild

Moderate

Severe

Allergies(Required)

None

Mild

Moderate

Severe

about Vitality Aesthetic & Regenerative Medicine

Caring, Qualified and Experienced.
It is our mission to provide you with
the most exceptional experience from
check-in to post-care.

Vitality Aesthetic & Regenerative Medicine

Route

Your location: No route could be calculated.

ADDRESS

2595 Tampa Rd Suite P, Palm Harbor, FL 34684

727-771-3915

varmedicine@gmail.com

Open Mon 7:30-5:30, Wed 8-6, Fri 7:30-5:30

RECENT PROCEDURES

Download New Patient Forms

Disclaimer Privacy Policy Sitemap