Individual ‘ADULT’ – History And Physical Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.It is extremely helpful to have you prepare some information before your first appointment. This ensures that our visit is as thorough and useful as possible. These forms include a questionnaire, diet diary, disclosures and consent form. Please complete all pages of the questionnaire. You can fill out the diet diary for any 3 days in a row between now and your appointment. Thank you for putting your time into this preparation and please remember to bring them with you to your appointment. LayoutFull Name *Age *Email Address *Marital Status *SingleMarriedSeparatedDivorcedWidowedCohabDate of BirthGender at Birth *MaleFemaleDo not want to disclosePhone Number *OccupationAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReason for Visit *Past Medical HistoryChronic Illnesses *Surgeries *Medications, Hormones and/or Supplements (including dosage) *Allergies *Reproductive System (Women only) *Family HistoryMother *Father *Siblings *Social HistoryLayoutOccupation *Alcohol Use *Diet *Tobacco Use *Recreational Drugs *Exercise *Review of SystemsPatients are often asked to check any symptoms they currently have or have had in the last 6-12 months. LayoutRespiratory *Shortness of BreathCoughWheezingChest TightnessHemoptysis (coughing up blood)Neurological *HeadachesDizzinessSeizuresNumbness or tinglingMemory loss or confusionEndocrine *Excessive thirstExcessive hungerHeat or cold intoleranceWeight gain or lossFatigueGenitourinary *Painful urinationFrequent urinationBlood in urineSexual dysfunctionMenstrual irregularities (for females)Musculoskeletal *Joint painMuscle painBack painSwelling in jointsLimited range of motionDermatological *RashesItchingDry or oily skinAcne or skin eruptionsMoles with changes in size, shape, or colorPsychiatric *DepressionAnxietyMood swingsHallucinations or delusionsSleep disturbancesCardiovascular *Chest PainPalpitationsShortness of breathLeg swelling or edemaHistory of fainting or syncopeSubmit