Medical History and Present Medical Condition Questionnaire

Date / Time

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Health Conditions

Check all that apply

Ear, Nose & Throat

Please Add Further Details If Required

Eyes & Vision

Please Add Further Details If Required

Neurological & Cognitive

Please Add Further Details If Required

Mouth & Oral Health

Bleeding Gums & Sore Mouth
Tooth Decay
Bad Breath
Other

Please Add Further Details If Required

Lungs & Airway

Please Add Further Details If Required

Heart & Circulation

Please Add Further Details If Required

Skin

Please Add Further Details If Required

Sleep

Please Add Further Details If Required

Genito-Urinary

Please Add Further Details If Required

Gastrointestinal

Please Add Further Details If Required

Hormones

Please Add Further Details If Required

Musculoskeletal

Please Add Further Details If Required

Immune / Autoimmune

Please Add Further Details If Required

Mens Health

Please Add Further Details If Required

Women Health

Should You Normally Be Mensturating Regularly?

If So, Are You Getting Regular Periods?

If No, Are You:

Have You Had A Pap Smear In The Last 5 Years?

Please Add Further Details If Required

Miscellaneous

Cancer
Undesired Weight Loss
Rapid Weight Gain
Other

Please Add Further Details If Required

Are You Undergoing Hormonal Replacement Therapy Or On Birth Control?

Yes
No

How Often Do You See Your GP For a Check Up Or Other?

Are You Currently Under A GP Or Doctor For Treatment? If So What?

Please Add Further Details If Required

Have You Had Any Surgeries In The Last 10 Years?

Please Add Further Details If Required

Do You Have Any Other Health Concerns Not Mentioned?

Please Add Further Details If Required

Are You Experiencing Any Stresses, Mood Conditions, Relationship Difficulties Or Substance Related Conditions That You Would Like Resources For Or A Confidential Referral?

Please Add Further Details If Required

Medication, Drug, & Supplement Use

Do You Take Any Over The Counter Or Prescription Medications Occasionally Or Regularly?

Please Add Further Details If Required

How Often Do You Consume Alcohol?

Each Time You Consume Alcohol, How Many Drinks Do You Have (one drink = 12 ounces of beer, 5 ounces wine, 1.5 ounces hard liquor)?

How Often Do You Use Recreational Drugs

Thank You For Taking The Time To Complete This Form

Your answers will be kept strictly confidential in line with GDPR legislation and only used in relation to coaching support.

Medical History and Present Medical Condition Questionnaire

Health Conditions

Medication, Drug, & Supplement Use

Thank You For Taking The Time To Complete This Form

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