MEDICAL HISTORY QUESTIONARRE:

DIRECTIONS: Please take a few minutes to fill out this medical history questionnaire for further evaluation.

General Health Information

In general, how would you rate your quality of health?

 Outstanding Good Have some concerns Poor

How would you rank your daily nutrition/eating habits?

 Outstanding Good Adequate

 Needs improvement Poor

How often have you visited your doctor within the past year?

 1 or less 2-5 Visits More than 6

Medical History Information

In the past 3 months have you experienced any unexplained weight loss/weight gain?

 Yes Weight loss was planned at 1 pound of weight loss per week for 12 weeks  No

Is anyone in your immediate family have a history of cardiovascular disease or diabetes? If so, describe below.

My mother’s side of the family has a history of cardiovascular diseases including: Hypertension, STEMI’s, and Atherosclerosis

Check all of the following symptoms that apply to you or that you have experienced in the past?

 Chest Pain/Discomfort Tachycardia (Heart Rate above 100bpm

 Hypertension Systolic BP >130

 Palpitations or feeling of racing/pounding heartbeat

 Hypotension Systolic BP<90

 Swelling of extremities

 Difficulty in ability to urinate

Have you been diagnosed with any gastrointestinal disorders or diseases within the past 3 years?

 Yes |  No

Do you have any bouts of heartburn or acid reflux after meals?

 Yes |  No

How frequent are your bowel movements? Explain below:

Once a day, usually at night upon waking in the morning.

Medical History Information (continued)

Check the following symptoms that apply to you:

 Neck Pain/ Back Pain

 General Weakness/ Malaise

Dizziness

 Memory Loss

 Unexplained Syncope

 Numbness and Tingling in Extremities

Facial Numbness

 Difficulty Swallowing

Uncontrolled salivation accompanied with drooling

Do you have any allergies to food or medication? Describe below

Unexplained hives 3 months ago, received antihistamine via IV and reaction went away without further incident.

Medical Information -Psychiatric

Have you been diagnosed or have been previously diagnosed with a psychiatric disorder within the past 3 years? If so, Explain:

 Yes |  No

Check the following symptoms that apply to you:

 Restlessness

 Trouble sleeping or waking in the middle of the night

Anxiety

 Mood Swings

 Lack of Motivation

 Depersonalization

Trouble Concentrating

 Feelings of dread or inability to cope

If you received a lab exam, please indicate the type of lab exam you received and for what reason:

Blood test / Breast exam / CT scan
MRI / X-ray / Received blood test for annual physical. 06/04/2014 All results normal.

Additional Medical Information:

Please list any other medical history not listed within this questionnaire including medication and supplementation list.

Minocycline 100mg twice a day, 500mg Vitamin C, Fish Oil tablets 1200mg, BCAA –Amino Acids, Mens Multivitamin, Metamucil Fiber twice a day.

Mike BortnowskiBasic NutritionMedical History Questionnaire—6/13/14