Medical Evaluation Form
Medical Evaluation Form
Please complete this form to help us assess your medical needs.
Patient Information
Name
Date of Birth
Sex
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Male
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Female
Phone number
Address
Lifestyle & Habits
Do you smoke?
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Never
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Rarely
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Occasionally
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Frequently
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Always
Do you consume alcohol?
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Never
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Rarely
-
Occasionally
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Frequently
-
Always
Do you use recreational drugs?
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Never
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Rarely
-
Occasionally
-
Frequently
-
Always
How often do you exercise?
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Never
-
Occasionally
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1-2 times per week
-
3-5 times per week
-
Daily
Do you follow a special diet?
If yes, please specify:
Medical History
Does anyone in your immediate family have a history of the following conditions?
Select all that apply:
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Heart Disease
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Diabetes
-
High Blood Pressure
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Cancer
-
HIV
-
Stroke
-
Mental Illness
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None
Have you been diagnosed with any chronic conditions?
If yes, list conditions:
Are you currently taking medications?
Current Medications
Do you have any allergies?
Please specify, if any:
Current Symptoms
Please select the symptoms you are currently experiencing, if any:
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Fever
-
Cough
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Fatigue
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Headache
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Shortness of Breath
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Chest Pain
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Dizziness
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Nausea
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Joint Pain
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Rash
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None
How long have you been experiencing these symptoms?
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Less than 1 week
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1-2 weeks
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2-4 weeks
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Over a month
-
On a scale of 1 to 5, how would you rate your pain or discomfort?
Have your symptoms worsened in the last 48 hours?
Do you have any other concerns or symptoms that haven't been addressed?
If yes, please specify:
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