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THE PHILOSPHY COMMON DISEASE STRESS FAQ QUESTIONER Questioner   New Patent - Medical History Form   First Name Last Name Date of Birth Age Sex Male Female Address City Postal Code Marital Status S M W D CL Spose Name Phone Mobile Business Phone Medical History : Please indicate any conditions you have had which required regular medical attention. Year Condition Year Condition Arthritis Diabetes Asthma Gout Cancer Type Heart Murmur Cohn's Disease High Blood Pressure Irritable Bowel Disease Seizures Anemia Chronic Fatigue Prostate/Sexual Problem Eating Disorder Hepatis Type Herpes Type Chronic UTI Short Term Memory Loss Epstcin's-Barr Syndrome Decrese sex Drice Poor Sleep Other     Hospitalization : Please list all hospital admissions, fractured bones, any motor vehicle accidents or there major surgeries you may have had in the past. As in (Tonsils, Hernia, Appendix, Gall Bladder, Dental Extractions, Laser Surgery, Plastic Surgery, Child Birth or Others) Year Conditions or Reason for Surgery for Hospital Admission Allergies Yes No Please tell all type of allergies and type of reactions you had.   Family History Is there a history in your family of the following health problem? Please indicate mother, father, Maternal Franmother(MGM) Peternal Grandmother (PGM) Maternal Grandfather (MGF) Paternal Grandfather (PGF). Arthritis Blood Pressure Heart Disease Diabetes Kidney Disease Mental Illness Lung Disease Cancer (Type) Parkinson's Thyroid Tuberculosis Stroke Others :       General Health Qusetions You Smoke Yes No How Much How Long If you used to smoke, what year did you quit? Did you restart smoking? if so what year and for how long? Do you consume alchohol? Yes No Period Rerely Occasionally Socially Weekends Daily 0-2 2-4 4-8 8-12 More than 12 Occupation Place of Employment Date Date required for Appointment         Disclaimer

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