The Health & Longevity Clinic’s Medical History Click Here for PDF form: Family Medical History (General Health)Mother's sideFather's sideSiblingsIf above deceased cause of death:Childhood Health (Physical)(Emotional)Location of upbringing:Current Emotional Health:Current Predominant Emotion:Current Quality of Life:Current Relationship/Quality:Is there much stress in your life?What?Hobbies and recreational habits:Favorite time of year?Worse time of year?Do you have a regular exercise program?Please describe:Travel abroad within the past year?Where?Do you feel like you have a good appetite?Good eating habits?Please describe your average daily diet:MorningAfternoonNightPortion of Raw FoodTo Cooked FoodDo you get cravings?What/When?Preferred Tastes:SourBitterSweetSpicySaltyHow many packs of cigarettes do you smoke a day?How much coffee, tea or cola do you drink per week?How much alcohol do you drink per week?Please describe any recreational drug use (this info is strictly confidential):Have you ever abstained or "quit" anything?Do you have any nervous habits?What factors in your life seem destructive to your daily health?Please check if you now have, or if you ever have had any of the following:CancerDiabetesStrokeHeart DiseaseHeart AttackArthritisAsthmaAllergiesSeizuresParasitesHepatitisHIV/AIDSHerpesTuberculosisWeight DisorderHigh Blood PressureThyroid DisordersRheumatic FeverAddictive DisordersMental IllnessGeneral:FeversChillsFatiguePoor Sleep/InsomniaDream Disturbed SleepDepressionManiaEmotional ChangesTremorsSeizuresNight SweatsDay SweatingPoor BalanceWeight GainPoor AppetiteChange in AppetiteGeneral:Peculiar tastes or smellsSudden energy drops — what time of day?Strong thirst — for hot or cold drinks?HeadachesLocalized WeaknessBleeding or BrusingJoint PainCardiovascular:High Blood pressureLow Blood pressureIrregular heartbeatChest Pain/AnginaDizzinessFaintingCold SweatsSwelling of FeetSwelling of HandsDifficulty BreathingCold Hands of FeetPhlebitisBlood ClotsPalpitationsRespiratory:CoughAsthmaBronchitisPain with Deep BreathsDifficulty in Breathing when Laying DownEasily Winded with ExertionShortness of BreathCoughing of BloodProduction off Phlegm, what color?Gastrointestinal:NauseaVomitingIndigestionUlcersAbdominal Pain or CrampsDigestive DisordersBelchingBad BreathGasConstipationDiarrheaBlood in StoolsHemorroidsHerniaGenito-urinary:Pain on UrinationUrgent UrinationFrequent UrinationUnable to Hold UrineDecrease in UrineBlood in UrineImpotency/InfertilityGenital SoresKidney StonesWaking up to urinate, how often?Musculoskeletal:General AchesMuscular AtrophyMuscular WeeknessArthritisJoint InstabilityMuscle CrampsSpasmsRecent SprainsInjuries or FallsEar, Nose & Throat:Ringing in EarsPoor HearingEarachesEar DischargeSinus ProblemsNose BleedsRecurrent Sore ThroatSores on Lips or TonugeThirst w/o desire to drinkTeeth ProblemsGrinding TeethGum ProblemsFacial PainJaw ClicksEyes & Vision:GlassesPoor VisionBlurred VisionEye StrainCataractsGlaucomaEye PainEye DrynessEye RednessColor BlindnessNight BlindnessFloaters in VisionSpots in Front of EyesEye ItchinessSkin & Hair:RashesItchingEczemaUlcerationsHivesPimplesRecent MolesDandruffLoss of HairAny Change in Hair or Skin TextureNeuropsychologicalSiezuresConcussionDizzinessHeadachesMigrainesAreas of NumbnessLack of CoordinationLoss of BalanceFaintingDisorientationIrritabilityEasily Susceptible to StressEasily AngeredDepressionManiaAnxietyPoor MemoryHave you ever been treated for emotional, neurological or psychological problems?Pregnancy & Gynecology:Age at first MensesDays between MensesFirst date of last MensesHeavy or LightIrregular PeriodsPainful PeriodsNumber of Pregnancies.Number of BirthsMiscarriagesAbortionsDifficult BirthsPremature BirthsBreast LumpsClotsBirth Control?What Type?How Long?Currently?Fertility ProblemsVaginal DischargeVaginal SoresLast PAP SmearDo you experience changes in body and or Psyche prior to menstruation?Are there any other problems, conditions of observations that you would like to discuss?What are your goals for health and life?Submit
