Date of Last Visit Has your doctor ever said that you have HEART trouble? Have you ever had PAIN in your CHEST? Do you often FEEL FAINT or have DIZZY SPELLS? Has your doctor ever said that your BLOOD PRESSURE is too HIGH? Do you suffer from DIABETES? If yes, how often do you test your blood sugar levels? Never Rarely Once a week Several times a week Once a day Several times a day Have you been HOSPITALIZED in the LAST YEAR? Are you currently taking any prescribed or over the counter MEDICATIONS? If yes, please list ALL current medications including over the counter medications. Do you have an EATING DISORDER? Do you have BLADDER or BOWEL CONTROL problems? Do you suffer from ASTHMA or BREATHING DIFFICULTIES? Do you suffer from EPILEPSY? Have you used ALCOHOL or DRUGS in the past 24 hours? If yes, please list names and quantities used Is there a possibility that you are PREGNANT? If yes, are you receiving PRENATAL CARE? Would you like to receive information about PRENATAL CARE? Is there any other MEDICAL ISSUES that we should be aware of? Is there any CHILDHOOD ILLNESSES? Are your IMMUNIZATIONS up to date? Would you like to receive information about immunizations? Do you smoke TOBACCO? Would you like to receive information about smoking cessation? Has your doctor told you that you have HEPATITIS or HIV infection? Do you utlize Complimentary Health approaches
(i.e. dietary supplements, acupuncture, massage therapy, meditation, yoga, homeopathy, etc.)?