Q & A - Health History

Please fill out as much as you can in this form, and please take your time to fill it out carefully. The information you provide will assist me in formulating a complete health profile for you. All your answers are absolutely confidential.

Contact info

Name (required)
Email (required)
Address
City
State
Zip
Phone (home)
Phone (mobile)
Date of Birth
Age
Gender
Marital Status
Occupation

Personal History

Surgeries		please include date of procedure
Allergies		chemical, environmental, food, drugs,...
Medications		names, dosages
Vitamins / Supplements / Herbs
Exercise Days per week Length of workout Type of activity		Diet Meals per day Snacks Caffeinated drinks Alcohol per week
Short message to B.J. Wang

Personal History (cont')

arthritis  high/low blood pressure  cancer  ulcer  chronic fatigue  alcoholism  gastritis / pancreatitis  liver / gall bladder disease  hypo / hyperglycemia  diabetes  seizures  anemia  lyme disease  asthma

stroke  kidney disease  food allergies / intolerance  hepatitis  thyroid imbalance  chronic pain condition  infertility  heart disease  elevated blood cholesterol  diverticulitis / IBS  Raynaud's disease  respiratory allergies  impotence  emphysema

Family Medical History

	father	mother	sister	brother	grandmother	grandfather
diabetes
high blood pressure
seizures
allergies
heart disease
cancer
stroke
asthma
other