Health History QuestionnaireStep 1 of 714%Deepa B Verma, MD, ABIHM 3165 N. McMullen Booth Rd, D-2 Clearwater, FL 33761 (p) 727.754.2936 (f) 727.754.2937Health History Questionnaire All material in this questionnaire is strictly confidential and will become part of your medical recordToday's Date:(Required) MM slash DD slash YYYY Name(Required) First Middle Last DOB:(Required) MM slash DD slash YYYY Age:(Required)Gender:(Required) Female MaleHome Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Home Phone:(Required)Cell Phone:Work Phone:E-Mail(Required) Preferred Daytime Contact Phone:(Required) Home Cell WorkRace/Ethicity:Employer:PCP Name & Phone Number:(Required)Names of Specialists (if any):Date of Last Physical:Referred By:Main Reason For Visit:Past & Present Medical Conditions and Family History:Acid Reflux Self History Family HistoryAlcoholism Self History Family HistoryAllergies Self History Family HistoryAnemia Self History Family HistoryAnxiety Self History Family HistoryArthritis Self History Family HistoryAsthma Self History Family HistoryADD/ADHD Self History Family HistoryBipolar Disease Self History Family HistoryCancer & Type of Self History Family HistoryCataracts Self History Family HistoryClotting Disorders Self History Family HistoryCongestive Heart Failure Self History Family HistoryConstipation Self History Family HistoryCrohn's Self History Family HistoryDementia Self History Family HistoryDepression Self History Family HistoryDiabetes & Type Self History Family HistoryDiarrhea Self History Family HistoryDizziness Self History Family HistoryDrug Abuse Self History Family HistoryEating Disorder Self History Family HistoryEczema Self History Family HistoryFibromaylagia Self History Family HistoryGlaucoma Self History Family HistoryGluten Sensitivity Self History Family HistoryGout Self History Family HistoryGallbladder disease Self History Family HistoryHeart Attack/Angina Self History Family HistoryHeart Valve Disorder Self History Family HistoryHigh Blood Pressure Self History Family HistoryHigh Cholesterol Self History Family HistoryHIV Self History Family HistoryHyperthyroidism Self History Family HistoryHypothyroidism Self History Family HistoryImmune Problems Self History Family HistoryInfertility Self History Family HistoryInsomnia Self History Family HistoryIrregular Heartbeat Self History Family HistoryKidney disease/stones Self History Family HistoryLiver Disease/Fatty Liver Self History Family HistoryLyme Disease Self History Family HistoryMigraine Headaches Self History Family HistoryMultiple Sclerosis Self History Family HistoryObesity Self History Family HistoryOsteoporosis Self History Family HistoryPeripheral Arterial Disease Self History Family HistoryPsoriasis Self History Family HistorySchizophrenia Self History Family HistorySeizures Self History Family HistoryStroke Self History Family HistoryUlcers Self History Family HistoryWhere were you born?(Required)Do you travel internationally?(Required)How often do you travel internationally?(Required)When you travel, where do you go?(Required)Have you had(Required) Chicken Pox Measles Mumps Polio Rheumatic Fever NoAre you adopted?(Required) Yes NoIs your mother(Required) Alive Deceased UnknownAge & Current Medical/Psych Problems(Required)Age at Death & Cause(Required)Is your father(Required) Alive Deceased UnknownAge & Current Medical/Psych Problems(Required)Age at Death & Cause(Required)Do you have siblings?(Required) No Yes UnknownBrother(s) (Full & Half), Age(s), Medical/Psych Problems(Required)Sister(s) (Full & Half), Age(s), Medical/Psych Problems(Required)Is your maternal grandmother (MGM) (Alive/Deceased?)(Required) Alive Deceased UnknownCause of Death, Age, Medical/Psych Problems(Required)Is your maternal grandfather (MGF) (Alive/Deceased?)(Required) Alive Deceased UnknownCause of Death, Age, Medical/Psych Problems(Required)Is your paternal grandmother (PGM) (Alive/Deceased?)(Required) Alive Deceased UnknownCause of Death, Age, Medical/Psych Problems(Required)Is your paternal grandfather (PGF) (Alive/Deceased?)(Required) Alive Deceased UnknownCause of Death, Age, Medical/Psych Problems(Required)Past Surgeries & Hospitalizations:1. Name/Reason/DiagnosisYear2. Name/Reason/DiagnosisYear3. Name/Reason/DiagnosisYear4. Name/Reason/DiagnosisYear5. Name/Reason/DiagnosisYear6. Name/Reason/DiagnosisYear7. Name/Reason/DiagnosisYear8. Name/Reason/DiagnosisYear9. Name/Reason/DiagnosisYear10. Name/Reason/DiagnosisYear11. Name/Reason/DiagnosisYear12. Name/Reason/DiagnosisYearCurrent Height(Required)Current Weight(Required)Prescribed Pharmaceutical and/or Nutraceutical Medications & Dosages if Known:(Required)OTC Drugs/Vitamins/Supplements/Herbs & Dosages if Known:(Required)Known Drug Allergies/Sensitivities:(Required)Known Food Allergies/Sensitivities:(Required)Known Environmental Allergies:(Required)Lifestyle Questions:Are you trying to lose weight(Required) No YesIf yes, how many pounds?(Required)Highest weight(Required)Lowest weight(Required)Are you following a diet(Required) No YesIf yes, type(Required) Doctor Prescribed Atkins Mediterranean South Beach Raw Food Vegan The Zone Vegetarian Weight Watchers NutriSystem Jenny Craig Macrobiotic Cookie Glycemic Index Other(Required)How many BMs daily and is it formed/regular?(Required)Do you exercise(Required) No YesIf yes, what type of exercise?How many times per week?How many minutes per day?Have you ever been a member at a gym?Worked with personal trainer?Do you drink alcohol(Required) No YesWhat is the frequency?Are you dependent on alcohol?If so, for how many months/years?What is your preferred alcoholic beverage(s)?Do you currently abuse recreational or prescription drugs(Required) No YesFor how long and what types?(Required)Do you smoke(Required) No, never I used to for this many years Yes, current use.(Required)Packs per day(Required)Number of packs daily(Required)Since ageHow many hours of sleep do you get?(Required)Is it refreshing/restorative?(Required)Do you take naps during the day(Required) No YesDo you wake up in the middle of the night(Required) No YesHow many times and why?(Required)Have you ever been exposed to chemicals?Do you drink coffee?(Required) No YesIf yes to drinking coffee Black Coffee Cream Only Sugar Only Cream and Sugarcups daily(Required)Do you drink tea?(Required) No YesWhat types of tea?(Required)What do you put in your tea?(Required)Soda(Required) No Yescups daily(Required)cups weeklyWhat type of soda do you drink?Do you drink juice(Required) No Yescups daily and type(s)(Required)Do you use sweeteners(Required) No YesI use this typeHow many glasses of water do you drink daily?Type of water?What types of cravings do you have Sweet Salty Fatty CarbsWhat are your main sources of protein?How many fruits & vegetables do you eat daily?Types?How often do you eat fast food or at a restaurant?How many meals do you eat daily?Do you eat breakfast(Required) No YesIf yes, what?(Required)Describe your lunch(Required)Describe your dinner(Required)Do you snack between meals?(Required) No YesIf yes, what?(Required)Have you ever seen a therapist or a life coach?(Required)At what age did you feel your best? Or do you think it is yet to come?(Required)What do you enjoy most in life?(Required)What are you most scared of in life?(Required)What are your pet peeves?(Required)What are your hobbies?(Required)Are you religious or spiritual?(Required)Do you enjoy your job?(Required)Do you feel fulfilled in life?(Required)What are your life stressors?(Required)What is your sexual orientation?(Required)Have you ever been abused (physically, emotionally, sexually)?(Required)If you are in a relationship, is it healthy?(Required)Do you have emotional support?(Required)Who is in your household?(Required)Do you have pets?(Required)How would you describe your personality?(Required)Name 3 personal strengths(Required)Name 3 personal weaknesses(Required)What goals do you want to achieve in life?(Required)Have you ever considered aesthetic treatments for anti-aging?(Required)Whether you are male or female, would you consider organic skin care?(Required)Are you interested in laser skin resurfacing or microneedling?(Required)For women, would you consider vaginal rejuvenation to improve intimacy and incontinence?(Required)Do you feel anti-aging and aesthetic treatments are important to feel refreshed and rejuvenated?(Required)Have you ever considered stem cells or fillers or Botox/Xeomin to maintain youth or treat medical conditions?(Required)Birth and Childhood QuestionsHow was your Mother's pregnancy with you?(Required)Was it a healthy pregnancy?(Required) No YesDid she take any pharma meds?(Required) No YesDid she drink alcohol?(Required) No YesDid she do drugs?(Required) No YesWas she depressed?(Required) No YesHow old was she when she was pregnant with you?(Required)Were you born full-term or pre-term?(Required) full-term pre-termWere you born vaginally or via c-section?(Required) vaginally c-sectionWere you breast-fed or formula-fed or both?(Required) breast-fed formula-fed bothHow was your childhood?: (Select all that apply)(Required) I was sick a lot I was seldom sick I was hospitalized Overall, I was healthy I took a lot of antibiotics I seldom took antibiotics I took a lot of steroids such as prednisoneDescribe any major incidents or illness you had.(Required)FOR FEMALESHow many times have you been pregnant total?(Required)Living children(Required)Abortions(Required)Miscarriages(Required)Pre-term(Required)Full-term(Required)Stillborn(Required)Ectopic(Required)# C-sections(Required)# of Vaginal births(Required)Adopted children(Required)Have you ever been a surrogate?(Required)Have you tried IVF?(Required)Was it successful?(Required)Have you had a mammogram(Required) No YesHave you ever had a breast lump(Required) No YesWas the lump benign or malignant?(Required)Age of first period(Required)Date of your last period(Required) Regular IrregularHeavy bleeding No YesPainful periods(Required) No Yes# Days period lasts(Required)Are you sexually active(Required) No YesAre you satisfied(Required) No YesVaginal dryness(Required) No YesLoss of libido(Required) No YesLoss of orgasm(Required) No YesHot flashes/Night sweats(Required) No YesUrine leakage(Required) No YesHair loss(Required) No YesBreast tenderness(Required) No YesMood swings(Required) No YesDry skin/wrinkles(Required) No YesAdult Acne(Required) No YesFood cravings(Required) No YesSleep disturbance(Required) No YesFatigue(Required) No YesWear sunscreen/SPF products(Required) No YesFOR MALESLoss of aggressiveness(Required) No YesLoss of libido(Required) No YesLoss of confidence(Required) No YesDifficulty achieving erection(Required) No YesDifficulty maintaining erection(Required) No YesPremature ejaculations(Required) No YesPerformance anxiety(Required) No YesLoss of orgasm(Required) No YesLoss of masculinity(Required) No YesIrritability(Required) No YesMood swings(Required) No YesMemory loss(Required) No YesSleep disturbance(Required) No YesBreast enlargement/Tenderness(Required) No YesAbnormal penile discharge(Required) No YesProstate problems(Required) No YesSkin/Hair problems(Required) No YesFatigue(Required) No YesIncreased abdominal girth(Required) No YesLoss of muscle tone(Required) No YesTHANK YOU! BE HEALTHY. BE HAPPY. BE AWESOME(Required) I accept the Terms of Use *CAPTCHA