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Rating Your Heath
1. How do you rate your health?

2. How do you rate your Weight?
3. Estimated Weight Estimated Height FT IN
4. Do you exercise regularly?
Yes No
4a. Frequnecy:
 Daily several days a week weekly or less
4b. I work out at:
Home Gym Both
5. How do you rate your outdoor activity?
I am outdoors often Weekend Warrior Beach addict Backyard Warrior
Actively outdoors daily Seldom Sports participation Sporting events
5a. Do you remember to wear sunscreen?
Yes No
What is the SPF
6. Do you participate in any of the following activities?
Click all that Apply      
Weight training Yoga Golf Roller Blade/Ice Skating
Spinning Classes Karate/Martial Arts Tennis/Racquetball Hiking
Aerobics Organized Sports Cycling Walking
Pilates Swimming Gym Membership Coaching
Jogging Dieting Boating Meditation
Competitive Running Diet Support groups Skiing/Snowboarding Other

7.   How do you rate you stress levels? 
High Average Situational Low
7a. What causes your stress (i.e. Work)? 
8.   How do you rate you sleep habits?

Erratic Average Restless Excellent
8a. How many hours of sleep to you get a night? 
8b. What is the cause of your sleeplessness?
Click all that apply    
Financial Stress General Anxiety
Work Stress Insomnia
Family Stress Depression
Pain Other
9. How do you describe your diet?
Healthy Organic Healthy Vegetarian Average Below Average Poor
10. How often do you see your Dr.?
Only when I am sick I get my yearly checkups Not if I can help it
11. Do you use any of the following?
Vitamins Herbal Supplements Neither

How often do you use Vitamins?
Daily Weekly Monthly

Where do you purchase your Vitamins?
Grocery Store Pharmacy Specialty Supplement Store Online Catalog/Direct Mail

How often do you use Herbal Supplements?
Daily Weekly Monthly

Where do you purchase your Herbal Supplements?
Grocery Store Pharmacy Specialty Supplement Store Online Catalog/Direct Mail

12. Do you perform self breast exam?
Yes No
How often? Once a month twice a year Yearly almost never
13. Have you considered vaccination for HPV (Human Papilloma Virus)?
Yes No Not sure
12. Do you perform a testicular exam?
Yes No
How often? Once a month twice a year Yearly almost never
13. How often do you get a prostate exam?
Once a Year Once every 2 years Never
12.  Have you had/have any of the following conditions?
Acne COPD HRT-Hormone Replacement Therapy Rheumatoid Arthritis
ADD/ADHD Crohn’s Disease Hypertension Restless Legs Syndrome
Allergies Dental Health IBS Schizophrenia
Alzheimer's Depression Incontinence/OAB Skin Cancer
Anxiety Disorders Diabetes Insomnia Sexual Conditions
Arthritis Diet & Weight Loss Menopause Sinusitis
Asthma Eczema Mental Health Skin & Beauty
Back Pain Emphysema Migraines Or Headaches Skin Problems
Bipolar Disorder Epilepsy Multiple Sclerosis Sleep Disorders
Bladder Control Erectile Dysfunction Nail Fungus Snoring
Blindness Fibromyalgia Obesity Spinal Injury
Breast Cancer Fitness Leukemia Stroke
Bronchitis Genital Herpes Lung Cancer Ulcerative Colitis
Cancer GERD/Acid Reflux Parkinson's Disease Vision-Glasses
Cholesterol Heart Disease Pregnancy Vision-Contacts
Chronic Heartburn/GERD Prostate-Enlarged   Other
Cold & Flu Hearing Loss Prostate Cancer  
Colorectal Cancer High Blood Pressure Psoriasis
               
Additional questions about your high blood pressure
Do you treat it with:
Diet/Lifestyle change
Prescription
Both
Which do RX do you take?
Ace Inhibitors
Capoten (captopril)
Vasotec (enalapril)
Prinivil, Zestril (lisinopril)
Lotensin (benazepril)
Monopril (fosinopril)
Altace (ramipril)
Accupril (quinapril)
Aceon (perindopril)
Mavik (trandolapril)
Univasc (moexipril)
  Other
Angiotensin II Receptor Blocker
Cozaar (losartan)
Diovan (valsartan)
Avapro (irbesartan)
Atacand (candesartan)
  Other
Beta Blockers
Sectral (acebutolol)
Tenormin (atenolol)
Kerlone (betaxolol)
Zebeta (bisoprolol)
Coreg (carvedilol)
Normodyne, Trandate (labetalol)
Lopressor, Toprol-XL (metoprolol)
Corgard (nadolol)
Levatol (penbutolol)
Visken (pindolol)
Inderal, Inderal LA (propanolol)
Betapace (sotalol)
Blocadren (timolol)
  Other
Calcium channel Blockers
Norvasc (amlodipine)
Plendil (felodipine)
DynaCirc (isradipine)
Cardene (nicardipine)
Procardia XL, Adalat (nifedipine)
Cardizem, Dilacor, Tiazac, Diltia XL (diltiazem)
Isoptin, Calan, Verelan, Covera-HS (verapamil)
  Other

Additional questions about your Diabetes
How do you treat your Diabetes?
Diet/Lifestyle
Oral Medication
Insulin Injections
Insulin Pump
What Type?
Type I
Type II
Additional questions about your Allergyes
What type of Allergyes do you suffer from?
Sun   Food
Airborne Milk
Hives (Urticaria) Nut
Latex Allergy Shellfish
Drug Egg
Pets/Animal Dander Fish
Occular (Eye) Allergyes Soy
Hay Fever (Allergyc Rhinitis) Wheat
Eczema (itchy skin ras)   Other
Cosmetic    
Seasonal    
Dust    
Environmental    
Plant (poison ivy etc...)    
Bee Sting    
Mold    
  Other    
Do you carry a EPI pen (Epinephrine Injection kit) for safety?
Yes    
No    
       
Do you have a medical alert bracelet?
Yes    
No    
       
Do you use any of the following to treat your Allergies?
  RX   OTC (over the counter)
Advair Benadryl
Alamast Claritin
Allegra Zyrtec
Allergy Shots Chlor-Trimeton
Alrex Dimetane
Astelin Tavist
Beconase Ocu-Hist (eye drop)
Benadryl Visine (eye drop)
Claritin D Afrin Nasal Spray
Deltasone Sudafed
Flonase Neo-Synephrine
Flovent Tylenol Allergy and Sinus
Naphcon    
Nasacort   Natural
Nasalcrom Butterbur (Petastites Hybridus)
Nasonex Saline (Nasal Spray)
Optivar Goldenseal
Patanol Spicy Foods
Pulmicort   Other
Rhincort    
Rhinocort Aqua   Immunotherapy
Semprex Rush
Singulair Oral
Vancenase Intranasal
Vasocon    
Veramyst    
Zaditor    
Zyrtec    
  Other    
       
Additional questions about your ADD/ADHD
How do you treat it?
Diet & Exercise
Stimulants
Adderall and Adderall XR
Concerta
Dexedrine
Focalin
Metadate CD and Metadate ER
Methylin
Ritalin, Ritalin LA
Vyvanse
Non-Stimulant
Strattera
Other Medications
Pamelor or other tricyclic antidepressants
Catapres or Tenex
Wellbutrin
Effexor
  Other
Additional questions about your Alzhiemers
What Type of Alzhiemers?
Early On-Set
Late On-Set
Familiar (F.A.D.)
What stage is the Alzhiemers?
Stage 1: No impairment
Stage 2: Very mild decline
Stage 3: Mild decline
Stage 4: Moderate decline (mild or early stage)
Stage 5: Moderately severe decline (moderate or mid-stage)
Stage 6: Severe decline (moderately severe or mid-stage)
Stage 7: Very severe decline (severe or late stage)
What level of care is provided?
Home Care w/Family
Home Care w/In home care
Nursing Home
Other
Additional questions about your Acne
What Type of Acne Do you suffer from?
Acne Rosacea
Acne Rosacea Keratitis
Acne Vulgaris
Acneiform Eruption
Severe Recalcitrant Nodular Acne
Worsening Acne
Other
What do you use to treat your Acne?
Oral Prescription
Topical Prescription
Over the Counter
Pro-Active
Other
Additional questions about your Type II Diabetes
ActoPlus Met
Actos
Amaryl
Apidra
Avandamet
Avandaryl
Avandia
Byetta
Cycloset
DiaBeta
Duetact
Exubera
Glucophage XR
Glucovance
Glycron
Glynase
Glynase PresTab
Glyset
Gucotrol
Humalog
Humalog Pen
Humilin 70/30
Humulin N
Janumet
Januvia
Lantus
Lantus Solstar
Levemir
Novolin
Novolog Mix
Orinase
Prandimet
Prandin
Precose
ReliOn/Novolin 70/30
Riomet
Starlix
Symlin
Symlin Pen
Tolinase
Other
Additional questions about your Type I Diabetes
Apidra
Exubera
Humalog
Humulin 50/50
Humulin N
Humuline 70/30
Iletin
Lantus
Levemir
NovaLog Mix 70/30
Novolin R
Novolog
NovoLog FlexPen
Novolog Mix PenFill
Novolog Mix FlexPen
Relion Novolin
Sandostatin LAR
Symlin Pen
Velsulin
Other
Additional questions about your Anxiety
What type of Anxiety do you suffer from?
Anxiety
Anxiety associated with Menopause
Anxiety due to Cardiac Asthma
Anxiety with Depression
Generalized Anxiety Disorder
Night Terrors
Nonpsychotic Anxiety
Pain with Tension and Anxiety
Preoperative Anxiety
Severe Anxiety
Social Phobia
Other
How do you cope with your Anxiety?
Exercise
Medication
Therapy
Will Power
Alcohol or Drugs
Over the Counter medications
All Natural Supplements
Other
What medication do you use?
Xanax Oral
Ativan Oral
Lorazepam Oral
Alprazolam Oral
BuSpar Oral
Valium Oral
Hydroxyzine HCl Oral
Buspirone Oral
Diazepam Oral
Vistaril Oral
Doxepin Oral
Herbal Supplement
Other
Additional questions about your Arthritis

Did a Dr. Diagnose your Arthritis?
 Yes
Which Kind?
Rhuematoid Arthritis or Gout
Osteoarthritis (Degenerative, inflamation, stiffness, Pain)
Psoriatic Arthritis (Usually associated with Psoriasis)
Other (there are over 100 types of arthritis)
No
What kind of symptoms do you have?
Aching in my knees, joints
Soarness and inflamation
All over body Ache
constant fatique

Have you been tested for Fybromyalgia?
Yes
No

Which common treatment are you trying?
Acupuncture
Arthroscopy
Hip Replacement Surgery
Knee Replacement Surgery
Joint Fusion
Celebrex
Enbrel
Methotrexate
Naproxen
Remicade
Tylenol w/Codeine
Ibuprofen
Other

What type of Back Pain do you suffer from?
Pain from an Injury
Upper Back Pain
Herniated Disc
Lower Back Pain
Back Pain do to pregnancy
Menstrual Back Pain
Sciatica
Scoliosis
Osteoporosis
Degenerative Disc Disease
Ankylosing Spondylitis (Arthritis of the spine)
Old Age
Weight Related back pain
Other

What do you do treat your back pain?
 Exercise -gym, lifting
Exercise-walking, low impact
Yoga
Stretching
Physical Therapy
Chiropractor
Ibuprofen
Acetaminophen (Tylenol)
Aleve
Diclofenac
Flexeril
Ice or Heat
Motrin
Naprosyn
Soma (carisopodol)
Oxycontin
Tylenol w/ codeine
Other

Additional questions about your Erectile Dysfunction

What do you think you cause is?
Depression
Stress
Disinterest in Sex
Physical-Unable to get or maintain an erection
Prostate

What are you doing to treat_your_ED?
Therapy
Penile Prosthesis
Vacuums/Pumps
Natural Remedies
Sex Therapy-Individual or Couples
Cialis
Viagra
Levitra
EDEX-Aprostadil
Coverject-aprostadil
Prostin VR-Aprostadil
MUSE-Suppository Aprostadil
Testosterone Replacement Therapy
Xanax
Other Anti-depresant or Anti-Axiety RX

Additional questions about your hearing loss
What is the cause of your hearing loss?
Noise-Job related
Noise-Entertainment related
Genectics
other

Do you use a hearing Aid?
Yes
No

Is your hearing aid device covered by your insurance?
Yes
No


Additional questions about your vision
Are you nearsighted or Farsighted?
Nearsighted
Farsighted

Do you wear contacts too?
Yes
No

if No, Why don't you use contacts?
Uncomfortable
I like my glasses
too much work
I have an Astigmatism
Other

Have you considered Laser Eye Surgery?
Yes
No


If No, Why?
Too Scary
Too Expensive
Not Ready
other

Additional questions about your vision
Are you nearsighted or Farsighted?
Nearsighted
Farsighted

What type of contacts to Wear?
Daily's
Weekly's
Hard
Other

Do you wear glasses too?
Yes
No

If Yes, Why?
Different Look
Give my Eyes a rest
Back up
Other

Have you considered Laser Eye Surgery?
Yes
No


If No, Why?
Too Scary
Too Expensive
Not Ready
other

 

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