Questionnaire

General Profile

First name

Last name

Address

City

State

Zip

Home Phone

Cell Phone

Sex	Race	Age
Weight (pounds)	Height (inches)

Social History / Habits

Tobacco Use: Yes No

Check One: Current Use Past Use

Type: Cigarettes Smokeless Cigars

Amount used per day

Last use (month/year)

Total number of years used

Alcohol Use: Yes No

Check One: Current Use Past Use

Type: Beer Wine Mixed Drinks Hard Liquor

Amount used per day

Last use (month/year)	Total number of years used
Drug Use: Yes No	Check One: Current Use Past Use

Type: Marijuana Cocaine Heroin Prescription Drugs Other

Route

Last use (month/year)

Total Number of Years Used

Sexual History

Have you ever been sexually active? Yes No

How many sex partners currently?

How many sex partners in your lifetime?

Male Female Both

Rate your condom use

Have you ever had a sexually transmitted infection? Yes No

If yes, please select from the following options:

Chlamydia Gonorrhea Syphilis
Trichomonas HIV Herpes HPV
Genital Warts

Menstrual History

Age at very first period?	Number of days between each period?
Last Period? (month/year)	Number of pregnancies?	Number of childbirths?
Breastfeed? Yes No

Medical History

Please list all surgeries:
Please list all current medications:

Check all diagnosis listed below that you or a family member have been given. Please give any needed details, the approximate year of diagnosis, and if treatment is currently being given. Indicate to whom the diagnosis was given by making "Y" for yourself, "M" for mother, "F" for father, "S" for sibling, "G" for grandparent, and "O" for other next to each diagnosis.

Cardiovascular System (Heart)

Pulmonary System (Lungs)

Dermatologic (Hair/Skin/Nails)

Gastrointestinal (Digestion/Bowels)

Nervous System (Brain/Nerves)

EENT System (Eye/Ear/Nose/Throat)

Musculoskeletal (Bones/Joints/Muscles)

Endocrine System (Hormones/Glands)

Hematologic (Blood/Lymph Nodes)

Urinary System (Bladder/Kidney)

Immune System

Psych System (Mental Health/Addiction)

Dental (Teeth/Gums)

I certify that I am 18 years of age or older, and I have read and understand the terms listed in the disclaimer. I understand that this health risk assessment is for informational and educational purposes only.

	Year / Details of Diagnosis	Who was diagnosed	Currently being treated
High Blood Pressure			Yes No
Heart Attack / Coronary Artery Disease			Yes No
Congestive Heart Failure			Yes No
High Cholesterol			Yes No
Irregular Heartbeat (Atrial Fib/Bradycardia/SVT)			Yes No
Valve Disease			Yes No
Infectious (Rheumatic, Endocarditis)			Yes No
Cardiomyopathy			Yes No
Pacemaker / Defibrillator / Transplant			Yes No
Other			Yes No

	Year / Details of Diagnosis	Who was diagnosed	Currently being treated
Asthma			Yes No
Emphysema/COPD			Yes No
Cystic Fibrosis			Yes No
Pulmonary Embolus (Blood Clot)			Yes No
Pulmonary Hypertension			Yes No
Tuberculosis			Yes No
Cancer			Yes No
Other			Yes No

	Year / Details of Diagnosis	Who was diagnosed	Currently being treated
Cancer (Melanoma, Basal Cell, Squamous)			Yes No
Eczema			Yes No
Psoriasis			Yes No
Alopecia (Hair loss)			Yes No
Acne			Yes No
Other			Yes No

	Year / Details of Diagnosis	Who was diagnosed	Currently being treated
GERD (acid reflux, gastritis, esophagitis)			Yes No
Irritable Bowel Syndrome (IBS)			Yes No
Polyps (Stomach/Colon)			Yes No
Ulcerative Colitis			Yes No
Crohn's Disease			Yes No
Cancer (Colon/Esophageal/Stomach)			Yes No
Liver Disease (Cirrhosis/Hepatitis)			Yes No
Ulcers (Stomach/Intestinal)			Yes No
Gallbladder Disease			Yes No
Fatty Liver (Non-Alcoholic, Alcoholic)			Yes No
Diverticulosis/Diverticulitis			Yes No
Pancreatitis (Acute/Chronic)			Yes No
Other			Yes No

	Year / Details of Diagnosis	Who was diagnosed	Currently being treated
Migraines			Yes No
Multiple Sclerosis (MS)			Yes No
Dementia (Alzheimer's/Vascular)			Yes No
Stroke			Yes No
Epilepsy/Seizures			Yes No
Parkinson's Disease			Yes No
Neuropathy			Yes No
Tumor (non-cancer)			Yes No
Cancer			Yes No
Other			Yes No

Questionnaire

General Profile

Social History / Habits

Sexual History

Menstrual History

Medical History

Cardiovascular System (Heart)

Pulmonary System (Lungs)

Dermatologic (Hair/Skin/Nails)

Gastrointestinal (Digestion/Bowels)

Nervous System (Brain/Nerves)

EENT System (Eye/Ear/Nose/Throat)

Musculoskeletal (Bones/Joints/Muscles)

Endocrine System (Hormones/Glands)

Hematologic (Blood/Lymph Nodes)

Urinary System (Bladder/Kidney)

Female Reproductive

Male Reproductive (Penis/Testes/Prostate)

Immune System

Psych System (Mental Health/Addiction)

Dental (Teeth/Gums)

Registration

H.E.A.L. Plan Registration

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