"...control food and you control the people." Former Secretary of State - Henry Kissinger
Medical & Health History
Confidential – Download -> Medical & Health History Information Record
Please Print
Name: ____________________________________________________Date: _____________________
Address: __________________________ City: __________________State: _________Zip: _________
Home Phone: ______________________Work: __________________ Mobile: ___________________
Email: _______________________________________________________________________________
Occupation: ______________________________ Employer: __________________________________
Date of Birth (dd/mm/yy)____________________Marital Status: _______________________________
Number of children: ________________________ Ages: _____________________________________
What is/was the health of your mother? ___________________________________________________
What is/was the health of your father? ____________________________________________________
What is/was the health of your siblings? ___________________________________________________
Emergency Contact (Name & Phone) ______________________________________________________
Name of primary care physician: ________________________________ Phone: ___________________
Main health concern or condition: ________________________________________________________
Reason for today’s appointment: _________________________________________________________
How long have you had this condition? ____________________________________________________
Have you been treated for this condition by another health care provider? ________________________
Do you consider yourself overweight? ____________ how much________________________________
Do you consider yourself stressed? _______ stress level: (0=none/10=extreme) ___________________
Do you know your Body Mass Index? _______________ if yes, what is it? ________________________
Are you now, or have you ever been a cigarette smoker? ________________ Packs a Day ___________
Years smoked ____________ if you quit, when? _________________ Do you want to Quit? ________
How did you hear about Health-eOptions, LLC? _____________________________________________
Please list all of the prescription medications, nutritional supplements, over the counter medications, homeopathic, remedies, herbs, or other substances you are currently taking.
Name of Medication (other) Dosage Frequency
(Example) Tylenol 250 mg. Once Daily
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Immunizations: Polio ___ Small Pox ____ Tetanus _____ Measles/Mumps/Rubella _____Pneumonia___
Please list any known allergens (food, drug, etc.) _____________________________________________
Please list any recent medical tests results you have, such as blood tests, etc.
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any major illnesses, surgeries, hospitalizations, or injuries. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Personal History & Risk Factors
(Please place an “X” by all that apply for you.
GENERAL PAST AND CURRENT MEDICAL HISTORY
____ Cancer: type____________ ____Easy Brusing ____Mumps
____Heart Disease ____Hepatitis: type_______ ____Chickenpox
____Diabetes ____Thyroid disease ____Small Pox
____Auto-immune disease ____Kidney Disease ____Measles
____Fibromyalgia ____Lupus ____Candida
____Anemia ____Rashes ____Eczema/Hives
____Alcoholism /Drugs ____AIDS/HIV ____Dental issues
NEUROLOGICAL/PSYCHOLOGICAL
____ Anxiety/Fear ____Anger/Frustration ____Grief/Sadness
____Lack of Joy/Mania ____Worry/Over-thinking ____Depression
____ADD or ADHD ____Panic Attacks ____Alzheimer’s
____Dementia ____Dizziness/lightheaded ____Fainting
____Mood Swings ____Mind Races ____Trouble Sleeping
____Bipolar Disorder ____Brain Fog ____Confusion
____Irritability ____Obsessive/Compulsive ____Poor Memory
____Numbness/Tingling ____Insomnia ____Loss of Balance
GASTROINTESTINAL
____ Abdominal Pain/Epigastric ____ Appetite Loss ____Clay Colored Stools
____Nausea ____Irregular bowel movements ____Hemorrhoids
____Heartburn ____Gall Bladder Disease/Stones ____Blood in stool
____Indigestion /Belching ____Black tarry stools ____Vomiting/Nausea
____Diarrhea ____Irritable Bowel Syndrome ____Ulcers
____Constipation ____Liver problems ____Gas
____Changes in appetite ____Leaky Gut Syndrome ____Bloating
RESPIRATORY, EYE, EAR, NOSE, THROAT, HEAD & NECK
____ Impaired Vision ____ Ringing in the ears ____Glasses/contacts
____Headaches ____Frequent Sore Throats/colds ____Sinusitis
____Earaches ____Tearing/Dryness ____Teeth grinding
____Allergies ____Gum Disease ____Bronchitis
____Asthma ____Nose Bleeds ____Hair Loss
____Slow wound healing ____Cough ____Wheezing
____Pneumonia ____Shortness of Breath ____Valley Fever
CARDIOVASCULAR
____ Heart Disease ____ Heart Attack ____Pacemaker
____High Blood Pressure ____Low Blood Pressure ____Stroke
____High Cholesterol ____Chest Pain ____Palpitations
____Varicose Veins ____Irregular Heart Beats ____Angina
____Arteriosclerosis ____High Triglycerides ____Arrhythmia
____Angioplasty ____Poor Circulation ____Lump in throat
MUSCULOSKELETAL
____ Back Pain ____ Neck/Shoulder Pain ____Muscle Spasms
____Joint Stiffness ____Body Aches & Pain ____Weakness
____Osteoporosis ____Arthritis ____Gout
____Muscle Cramps ____Fractures ____Bursitis
GENITO/URINARY TRACT
____ Kidney Disease ____ Kidney Stones ____Blood in urine
____Bedwetting ____Difficulty starting flow ____Burning urination
____Discharge ____Scanty urination ____Painful urination
____Urination during the night ____Dribbling after flow ____Frequent urination
WOMEN HEALTH
____ Painful periods ____ Heavy Flow ____PMS
____Breast Tenderness ____Moodiness ____Clotting
____Fibroids ____Nipple discharge ____Ovarian Cysts
____Other: _________________________________________________________________________
Are you pregnant now? ____________________ Method of birth Control ______________________
Age at first period: ___________________________ Start date of last menses: _________________
Age at Menopause___________________________ Length of period: ________________________
Hysterectomy? Yes______ No_____ Date: ______________________________________________
Hormone replacement therapy Yes_____ No________ Type_________________________________
MEN’S HEALTH
____ Impotence ____ Testicular Pain/swelling/redness
____Low libido ____Prostate problems
____Seminal emissions ____Vasectomy: Date_______________________________
Other: ____________________________________________________________________________
DIETARY
____ Sweet Cravings ____ Sugar Reactions ____Hypoglycemia
____Starch Cravings ____Fat Cravings ____Food Allergies
____Excessive Hunger ____Stress Eating ____Cannot skip meals
____No Hunger ____Other Food Cravings ____Mindless eating
____Irritable before meals ____Sleepy after meals ____Large Portions
____Sugary Drinks ____Indigestion after meals ____Salt Cravings
How many times do you eat out? __________ Fast food__________________
What types of meals to you usually eat out? (example) Lunch burgers
How many times to you cook per week? ___________________________________________________
What meals do you usually cook at home? (example) dinner ___________________________________
Are you a Vegetarian? ___________________ Vegan? ________________________________________
Are you on a restricted diet? _____________________________ if yes, type: _____________________
What diets have you tried? ______________________________________________________________
When? ___________________________________________________________________________
Have you been a participant in any kind of dietary education? ________________When? ___________
Who was the presenter? (American Heart Association, etc)_________________________________
Do you drink coffee? ______ how many cups? ______ do you drink soft drinks? _____ how many ____
Please list the foods that you normally have for breakfast, lunch, dinner and the time you normally consume them.
Typical Breakfast: ______________________________________________Time: __________________
Typical Lunch: _________________________________________________Time: __________________
Typical Dinner: ________________________________________________________________________
Typical Snacks: ________________________________________________________________________
Please complete a 24 hours recall for the most typical days – form is attached.
General Lifestyle:
How many hours do you sleep? _________________ Do you sleep well? _____________________
Do you have different habits for sleep on weekends (days off?) _______________________________
If so, what are they? ________________________________________________________________
How do you feel when you vary your sleep habits? ________________________________________
Do you exercise? ________________________ How often? _________________________________
What type of exercise do you do? ______________________________________________________
Do you have a ‘desk’ job? ________________ If yes, how many hours do you sit? ______________
What is your energy Level? (great, good, fair, poor) Comments: _____________________________
What time of day is your energy level the highest? ________________________________________
Do you consume energy drinks? ____________________________if so, which ones? ____________
What do you do when your energy level is low? (example: reach for a candy bar, etc.) __________________________________________________________________________________________________________________________________________________________________________
Please list the top four goals you wish to achieve in regards to your health and general well-being:
- ___________________________________________________________________________________________________________________________________________________________
- ____________________________________________________________________________________________________________________________________________________________
- ____________________________________________________________________________________________________________________________________________________________
- ____________________________________________________________________________________________________________________________________________________________
Is there any information that was not covered in this questionnaire that you feel is important to comment on? If yes, please explain: _____________________________________________________________________________________
Please Read and Sign
Balanced Lifestyles does NOT release any health information on this form or otherwise sensitive health information over the phone, or any other media except to the client signing this form in person with proper ID.
The above information is true to the best of my knowledge, I understand and accept that I am responsible for full payment of any account and that payment is expected at the time of service. Balanced Lifestyles does not take insurance, but will be happy to assist by an itemized invoice to be submitted to your insurance carrier.
By signing this Information form, I understand that Balanced Lifestyles’ nutritional balancing is a means to reduce stress, balance the body chemistry, and educate on the development of a healthier lifestyle, and is not intended as diagnosis, treatment or prescription for any condition or disease; and works as an unlicensed nutrition coach/consultant.
Signed: ______________________________________________________Date: ___________________
Patient Information
For Office use:
Height: ____________________ Weight: _________________ Age: _______________________
Blood Pressure: __________/______________ Heart Rate: _______________________________
Blood Sugar ____________________________
Eye Sight: _____________________________
Eating habits: __________________________
Sleep habits: ___________________________
Goals: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
24 Hour Recall food list: Please include all foods and beverages:
Breakfast _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Lunch _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Dinner _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Snacks _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How did you feel? Were you tired? Energized? Stressed? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Water: (total number of glasses) _________________________________________________________
Vitamins: Which type and amount: _______________________________________________________
Authorization Form
I, ___________________________________________________, in affixing my signature to this authorization form, do hereby agree to and understand the following:
- That Brenda Bilek, PhD, is a natural health counselor who is legally able to instruct and educate others in self-help methods of health such as the use of proper exercise, diet, nutritional supplements, water, sunshine, fresh air, herbs, rest and attitude;
- That Brenda Bilek, PhD in no context of the phrase “practices medicine” and therefore does not diagnose, prescribe, treat, administer, cure, heal or otherwise perform a duty that is reserved for those who are licensed to do so;
- That the instruction concerning a healthful lifestyle is incidental to any particular illnesses and diseases I may have and is therefore not made in direct reference to these;
- Any healing of illnesses or diseases I may experience as a result of following the instruction of Brenda Bilek, PhD, was purely the result of the body itself once a naturally correct way of living was employed, for it is only the body that heals itself, not any person;
- That no claims or guarantees have been made as to any health benefits that may result from my following instruction given by Brenda Bilek, PhD, concerning a naturally correct way of living;
- That the instruction given by Brenda Bilek, PhD, in no way replaces proper medical care, and that I am free to choose a naturally right lifestyle;
- That under penalty of perjury I am not an agent of any branch of the federal, state, or local government for any agency thereof, with intent to entrap or entice Brenda Bilek, her staff, employees and/or associates into breaking any federal, state, or local law whatsoever, acting either on my own behalf or on behalf of the agency of the government or on behalf of any government agency directly;
Signed: _________________________________________________________________________
Date: __________________________________________________________________________
PERMISSION & AUTHORIZATION FORM
I specifically authorize Brenda Bilek, PhD, Certified Health Coach, a non-licensed consultant, to perform nutritional determination to develop a natural complementary health improvement program for me that may include dietary guidelines, nutritional supplements, exercise, educational materials, etc., in order to assist me in improving my health and not for the treatment or ‘cure’ of any disease.
I understand that nutritional determination is safe, non-invasive and uses natural methods of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems.
I understand that nutritional determinations are not methods for ‘diagnosing’ or the ‘treatment’ of any disease or medical condition.
No promise or guarantee has been made regarding the results of any natural health, nutritional or dietary programs recommended, but rather I understand that these determinations, if utilized, are ways by which the body’s responses can be used as an aid to determine possible nutritional imbalances, so that safe, natural programs can be developed for the purpose of bringing about a better state of health.
I have read and understand the foregoing
This permission form applies to subsequent visits and consultations.
Print Name: ___________________________________________________________________
Address: ______________________________________________________________________
City: __________________________________State: ______________________Zip: ________
Phone: ________________________________________________________________________
Signed: _______________________________________________________Date: ____________
(If minor, signature of parent or legal guardian required)