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Contact Us
Patient Medical History
BioLogic Health
Patient Medical History
Please complete in as much detail as possible
Patient Email Address
Patient Name and Surname
ID Number
Title
Mr
Mrs
Dr
Master
Ms
Patient Cell Number
Residential Address
Age
Gender
Relationship Status
Married
Separated
Divorced
Widowed
Single
Referred By
Date of First Consultation
REASON FOR CONSULTATION:
Why are you Here?
Only List the top 4 reasons and their duration
Reason 1
Reason 2
Reason 3
Reason 4
MAIN SYMPTOMS - Not diagnosis!
Tell me what you feel and since when.
Symptom 1
Symptom 2
Symptom 3
Symptom 4
Symptom 5
Symptom 6
Symptom 7
Symptom 8
EXISTING MEDICAL CONDITIONS:
What are you currently being treated for and for how long?
Medical Condition 1
Medical Condition 2
Medical Condition 3
Medical Condition 4
Medical Condition 5
Medical Condition 6
Medical Condition 7
Medical Condition 8
CURRENT MEDICATION:
Please specify dosage and indicate for how long you have used this
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
PREVIOUS SURGERY and age at the time of surgery.
(incl. cosmetic, orthopaedic, dental, childhood, minor or post-trauma)
Surgery 1
Surgery 2
Surgery 3
Surgery 4
Surgery 5
HOSPITAL ADMISSIONS:
Have you ever been admitted to hospital for any other reason?
Please give details (incl. Pscychiatric or Rehab)
Hospital Admission 1
Hospital Admission 2
Hospital Admission 3
INFECTION HISTORY
Have you ever been treated for Tick bite or a Spider bite or any other Parasite infection?
Yes
No
If Yes, Please give the details below
SUPPLEMENTS
Do you use any supplements, homeopathic remedies, and or natural products?
Please Specify
Product 1 and duration of use
Product 2 and duration of use
Product 3 and duration of use
Product 4 and duration of use
Product 5 and duration of use
Product 6 and duration of use
Please list any supplements or medications you have discontinued or changed due to NEGATIVE REACTIONS
ALLERGIES
Please List any Allergies to Foods / Medicines / Animals / Dust / Grasses / Jewellery / Other
DENTAL HISTORY
Number of Metal Fillings?
Have you ever had any Removed?
Yes
No
Number of Crowns?
Any Braces or Retainers still Present?
Yes
No
Do you use a Bite Plate or Grind your Teeth?
Yes
No
Other Dental Issues?
PREVIOUS MEDICAL CONDITIONS:
Have you ever been diagnosed or suspected of having the following?
Please select all relevant options.
Anxiety
Arthritis
Asthma
Cancer
Cardiac Disease
Cholesterol
Chronic Fatigue
Circulatory Disorder
Depression
Diabetes
Eczema
Epilepsy
Fibromyalgia
Gout
Hepatitis
HIV
Hypertension
Kidney Stones
Malaria
Migraine
Renal Disease
Spastic Colon
Psoriasis
Thyroid
Tick Bite Fever
Gallstones
Headaches
Hey fever
Porphyria
Diverticulitis
Crohn's
Ulcerative Colitis
Lung Disease
COPD
Other
If Other, please specify
FAMILY HISTORY:
Please list any medical problems and/or cause of death of the following family members.
Father' s Age
Father
Alive
Deceased
Father's Medical Problems or Cause of Death
Mother' s Age
Mother
Alive
Deceased
Mother's Medical Problems or Cause of Death
FAMILY HISTORY:
Please list any medical problems and/or cause of death of the following family members.
Sibling 1's Age
Sibling 1
Alive
Deceased
Sibling 1's Medical Problems or Cause of Death
Sibling 2's Age
Sibling 2
Alive
Deceased
Sibling 2's Medical Problems or Cause of Death
Sibling 3's Age
Sibling 3
Alive
Deceased
Sibling 3's Medical Problems or Cause of Death
WORK HISTORY
What do you currently do?
Where have you worked in the past?
How many hours do you work per week?
How many hours do you spend in traffic per week?
Do you like what you do?
Yes
No
BODY COMPOSITION: Please Complete if Known
Current Weight (in kg)
Desired Weight (in kg)
Best Ever Weight (in kg)
Heaviest Weight (in kg)
Height (in meters)
Waist measurement (in cm)
Hip measurement (in cm)
Ratio of Waist to Hip
Weight gain or loss in the last 5 years?
Reason for weight gain or loss?
SMOKING
Smoker
Ex
Current
Never
How many per day?
For how many years?
When last?
ALCOHOL
Type of alcohol and a rough estimate of amount per week?
Previously drank more?
Yes
No
Why the change?
EXERCISE
Type of exercise?
Frequency of exercise?
How do you feel after you exercise?
REGULAR HOBBIES
List of Hobbies (include bee keeping / horse riding / small home animals / hiking or other exposure to outdoors and nature areas)
SOCIAL
Please Select
Single
Married
Divorced
Remarried
Co-Habit
Kids at Home
DIET
Do you follow a specific type of diet programme?
(eg Banting, Paleo, Weight Watchers, Intermittent Fasting)
FLUID
Daily intake of water?
How much Coffee do you consume in a day?
How much Tea do you consume in a day?
How much Sugar do you consume in a day?
How much Sweetner do you consume in a day and what type?
How many Energy Drinks (eg Red Bull) do you consume in a day?
What else do you drink?
SLEEP
Quality of Sleep
Average number of hours per night?
Average Bedtime?
Average Wake Time?
Do you feel refreshed in the morning?
Do you experience any of the following?
Please select
Struggle to fall asleep
Must use a sleeping tablet
Wake in the early hours and can't sleep again
Snore
Stop breathing
RELIGION
Spiritual or Religious affiliations?
NARCOTIC USE
Previous use of any Drugs or Hallucinogens?
Yes
No
If Yes, please select relevant options
Mushrooms
Ayahuasca
Ibogaine
LSD
MDMA
Dagga
Cocaine / Heroine / TIC
Previous rehab admission for addictions?
PETS
What pets do you keep?
BODY SYSTEMS
MOOD: Do you experience any of the following?
Please Select
Happy
Anxious
Obsessive
Agressive
Irritable
Depressed
ENERGY: Do you experience any of the following?
Please Select
Permanent Fatigue
Fluctuation
Afternoon Dips
Morning Tiredness
Dips a few hours after exercise
Plenty of energy
ABDOMINAL: Do you experience any of the following?
Please Select
Cramping
Diarrhoea
Constipation
Heartburn
Ulcers
Hiatus Hernia
Gastroscopy
Colonoscopy
Previous Surgery
Bloating
Feel Full Quickly
Burping
Haemorrhoids
Spastic Colon
IBS
SIBO
H. Pylori
Bleeding - top or bottom
HEART: Do you experience any of the following?
Please Select
Chest Pain
Palpitations
Angina
Irregular Heart Rate
Previous Angiogram
Heart Murmur
Heart Failure
Fluyid Retention
Short of Breath Quickly
High Blood Pressure
Low Blood Pressure
Cholesterol Meds
LUNGS: Do you experience any of the following?
Please Select
Short of Breath
Cough
Asthma
Emphysema
Still Smoking
Fingers go Blue
JOINTS AND MUSCLES: Do you experience any of the following?
Please Select
Aches and Pains
Cramping
Stiffness
Weakness
Joint Pain
Back Pain
NERVES: Do you experience any of the following?
Please Select
Weakness
Pins and Needles
Burning Feet
Shooting Pains
Ataxia/Off Balance
Tremor
BLADDER: Do you experience any of the following?
Please Select
Incontinence
Leak if sneeze
Frequent Infection
Get up at night
Urgency if need to go
Weak stream
Female Patients Only
GYNAE: Have you been diagnosed with any of the following?
Please Select
Oestrogen Sensitivity
Cancer
Last Visit to Gynae?
Last Pap Smear?
Last Mammogram?
Last Sonar?
IMMUNE SYSTEM: Do you experience any of the following?
Please Select
Get sick easily
Slow to heal or recover
Frequent Antibiotics
Antihistamines
Cortisone
Chemotherapy
HORMONES: Do you experience any of the following?
Please Select
Fatigue
Feel Hot
Always Cold
Sweat a lot
Sweat too little
Hot Flushes
Crave Salt/Sugar or Chocolate
Afternoon Energy Dips
Poor Sleep
Swelling in Neck
Cold Hands or Feet
Poor Circulation
PSYCHOLOGY: Do you experience any of the following?
Please Select
Depression
Bipolar
Anxiety
Schizophrenia
Previous Self-Harm
Addiction History
SKIN: Do you experience any of the following?
Please Select
Dry
Oily
Scaly
Eczema
Psoriasis
Allergy/Rashes
Absesses/Acne
EYES / EARS / NOSE / THROAT: Do you experience any of the following?
Please Select
Spectacles
Contacts
Glaucoma
Dryness of eyes
Sinusitis / Postnasal Drip
Dizziness
Allergies
Vertigo / Dizziness
Polyps
Deafness
Lump in Throat
Thyroid
Do you experience any other symptoms?
MALE PATIENTS ONLY
Do you experience any of the following?
Please Select
Problems with erection or sensation
Problems with ejaculation
Low Libido
How long have these been a problem?
Do you experience any of the following?
Please Select
Tendancy to procrastinate
Increase in anxiety levels
Grumpiness
Anti-social Behaviour
Snoring/Sleep Apnoea
Falling asleep in front of the TV
Fatigue
Urinating more at night
Must run if bladder full
Urine pressure low / have to wait for flow
FEMALE PATIENTS ONLY
Please rate symptoms from 1 to 10, where 1 is "okay" and 10 is "really bad"
Hot Flushes
Tiredness
Poor Sleep
Low Libido
Dry Skin
Vaginal Dryness
Hairloss / Thinning
Moodiness
Poor Memory
Unclear Thinking
Vaginal Thrush
Cellulite
Weight gain on tummy
Swelling / Fluid Retention
Bladder Leaking
Sweating
Hair growth on face
FEMALE PATIENTS ONLY - Pregnancies
Ectopic pregnancies?
Miscarriages?
No. of living children?
Ages of children
Normal deliveries?
Caesareans?
Difficulty falling pregnant?
Yes
No
Fertility treatments?
Medical conditions after pregnancy?
Weight gain that couldn't be lost?
Breastfed babies?
Yes
No
Depression after pregnancy?
FEMALE PATIENTS ONLY - Contraceptives
Current
Previous
Sterilised?
Yes
No
How do you respond to contraceptives?
Total years on contraceptives?
What was contraceptive used for?
Please select
Contraception
Skin / Acne
Period Control
FEMALE PATIENTS ONLY - Period History
Average length of cycle?
No. of bleeding days?
Last normal period?
FEMALE PATIENTS ONLY - Period Symptoms
How were your periods without contraceptives?
Please select
Regular
Irregular
Heavy
Light
Short
Long
Painful
Please rate your symptoms before/during your period from 1 to 10 where 1 is "mild" and 10 is "severe"
Headaches
Breast Tenderness
Moodiness
Feeling Bloated
Swelling
Irritability
Fluid Retention
Sugar Cravings
FEMALE PATIENTS ONLY - Hormone Therapy
Hormone Replacement Therapy (HRT)?
Yes
No
If Yes, Please specify HRT history
FEMALE PATIENTS ONLY - Medical
Have you been diagnosed with Poly Cystic Ovarian Syndrome (PCOS)?
Have you been diagnosed with Endometriosis?
FEMALE PATIENTS ONLY - Hysterectomy
Have you had a Hysterectomy?
Reason for the Hysterectomy?
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