Date:

First Name

Last Name:

Age:

Date of Birth: 

Sex:

Primary Care Doctor:

CURRENT AND PAST HEALTH HISTORY:

Are you in good health at the present time to the best of your knowledge?

Do you have or have you ever had high blood pressure?  If yes, indiate when.

Do you have or have you ever had high blood sugars (diabetes)?  If yes, indicate when.

Do you have or have you ever had elevated lipids or cholesterol?  If yes, indicate when.

List all of your medications with doses related to high blood pressure, elevated cholesterol, diabetes:

Have you ever had heart problems?  If yes, indicate when and the date of your last heart testing.

Do you have a personal or family history of colon cancer or colon polyps?  If yes, please state who has this history and when it occurred.

Do you have a personal or family history of breast cancer?  If yes, please state who had breast cancer and when it occurred?

Please list any other medical problems

Please list any sugeries you may have had

Do you use alcohol?  If yes, what amount and what frequency?

Do you use tobacco?  If yes, what type, amount and frequency?

Do you snore loudly?

Do you often feel tired, fatigued, or sleepy during daytime?

Has anyone observed you stop breathing during your sleep?

Is your neck circumference greater than 16 inches?

SCREENING HISTORY:

Have you had a colonoscopy?  If yes, when?

Have you had a mamogram?  If yes, when was your last mammogram?

Have you had a pap test?  If yes, when was your last pap test?

Have you had a prostate PSA exam?  If yes, when was your last prostate PSA exam?

EMPLOYEE LIFESTYLE EVALUATION

In the last month I:

In the past month I:

In the past month I: