"...control food and you control the people." Former Secretary of State - Henry Kissinger

Medical & Health History

Confidential – Download -> Medical & Health History Information Record

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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

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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:

___________________________________________________________________________________________________________________________________________________________
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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)