Omega Health & Wellness
8761 Perimeter Park Blvd #101
Jacksonville, Florida 32216
(904)374-6498



Health Questionnaire

Date: 09/22/17

First Name:
Middle Initial:
Last Name:



Male /
Female




How did you hear about us?
Google /
Website /
Facebook /
LinkedIn /
E-mail /
Twitter /
Friend



Primary Care Provider:


Emergency Contact Info




List of surgeries (with date):
Hospitalizations other than surgeries (with date):
Pertinent medical concerns of which we should be aware:
Have you ever received hormone therapy before?
Yes
/ No



Females Only
Regular /
Irregular


Yes
/ No

Do you have your ovaries?
Yes
/ No

PERSONAL MEDICAL HISTORY

CONDITIONS:

(check all that apply)
Anemia   GERD  
Arthritis/Gout   Heart Attack  
Asthma   Hepatitis  
Autoimmune Disease High Blood Pressure  
Blood Clot   High Cholesterol  
Cancer Irritable/Inflammatory Bowel
Colitis   Kidney/Bladder Problems
COPD/Emphysema Liver Disease  
Dental Problems/Gum Disease Neurological problems (Parkinson's, paralysis, etc.)
Depression/Psychiatric Problems Sexually Transmitted Disease
Diabetes   Skin problems (Psoriasis, Eczema, dermatitis)
Endometriosis   Stroke  
Epilepsy   Thyroid problem  
Fibromyalgia/Chronic Fatigue Syndrome Ulcer(s)  
Gallbladder Disease

SYMPTOMS:

     

Digestive Tract

Fatigue

Lungs

Skin

Belching Hyperactivity Asthma/Bronchitis Acne
Bloated feeling Lethargy Chest congestion Dermatitis
Constipation Restlessness Difficulty breathing Eczema
Diarrhea Sluggishness Shortness of breath Excessive sweating
Nausea

Eyes

Wheezing Flushing/hot flash
Passing gas Blurred vision

Mind

Hair loss
Stomach pains Dark circles Confusion Hives/rashes
Vomiting Itchy eyes Learning disabilities Itching

Ears

Sticky eyelids Poor concentration

Weight

Ear drainage Swollen eyelids Poor memory Binge eating
Ear aches Watery eyes Stuttering/stammering Compulsive eating
Ear infections

Head

Mouth & Throat

Cravings
Hearing loss Dizziness Canker sores Excessive weight
Itchy ears Faintness Chronic coughing Underweight
Ringing in ears Headaches Gagging Water retention

Emotions

Insomnia Often clear throat

Other

Aggressiveness Lightheadedness Sore throat Anaphylaxis
Anxiety/fear

Joint & Muscles

Swollen tongue/lips Chest pains
Depression Aches in muscles

Nose

Frequent illness
Irritability/anger Arthritis Excessive mucous Genital itch
Mood swings Feeling of weakness Hay fever Irregular heartbeat
Nervousness Limited movement Sinus problems Rapid heartbeat

Energy & Activity

Pain in joints Sneezing attacks Urgent urination
Apathy Stiffness Stuffy nose  


FAMILY MEDICAL HISTORY

          Mother Father Sibling
Arthritis/Gout        
Auto-immune disease      
Blood Clot        
Cancer      
Depression/Psychiatric Problems      
Diabetes        
Fibromyalgia/Chronic Fatigue Syndrome    
Heart Disease        
High Blood Pressure        
Neurological Problems (Parkinson's, MS, ALS etc.)  
Skin problems (Psoriasis, Eczema, dermatitis)    
Stroke        
Thyroid Problem        


Meals

Are you a vegetarian?
Yes
/ No
Do you eat breakfast?
Yes
/ No
Are the foods you eat mostly organic foods?
Yes
/ No
When you eat, do you predominantly..
Gorge /
Graze /
Starve
How many meals do you eat per day?
How many times daily do you eat healthy fats?
(avocado, coconut, olive oil, etc.)?
Approximately what time do you eat your last meal or snack?


Fluids:

How many caffeinated beverages do you drink per day?
How many carbonated beverages do you drink per day?
How many alcoholic beverages do you drink per week?
How many 8 oz. glasses of water do you consume per day?


Toxins


Do you suffer from any addictions?
Yes
/ No
List your addictions:


How often per day do you consume...
Sweets or sugar?
Artificial sweeteners?
Fat substitutes (canola, margarine, etc.)?
Are you currently a smoker?
Yes
/ No
Did you previously smoke?
Yes
/ No
For how long?
How many cigarettes do you smoke per day?
Does anyone else in your household smoke?
Yes
/ No


Environment


What time do you wake up?

What time do you go to bed?

I primarily sleep:

in the dark /
with low light /
with the TV on
/ other

I am seated for approximately hours per day.

Describe your exercise regimen or habits:




Medications

You may click the plus sign to add additional fields if you take more than one medication.
Add Medication Name Strength/Dosage How often? Date Started


Vitamins/Supplements

Please include: Vitamins, minerals, herbs, nutritional supplements, enzymes, etc.
Add Name Strength/Dosage How often? Date Started


Please click the number that best describes the intensity of your RECENT symptoms.

SYMPTOM

Mild

Severe

Anxiety

1

2

3

4

5

6

7

8

9

10

Arthritis/Joint Pain

1

2

3

4

5

6

7

8

9

10

Bladder Problems

1

2

3

4

5

6

7

8

9

10

Bloating

1

2

3

4

5

6

7

8

9

10

Breast Tenderness

1

2

3

4

5

6

7

8

9

10

Decreased Sex Drive

1

2

3

4

5

6

7

8

9

10

Depression

1

2

3

4

5

6

7

8

9

10

Difficulty Hearing/Ringing in Ears

1

2

3

4

5

6

7

8

9

10

Difficulty Reaching Climax

1

2

3

4

5

6

7

8

9

10

Dry Eyes/Blurred or Double Vision

1

2

3

4

5

6

7

8

9

10

Erectile Dysfunction (males)

1

2

3

4

5

6

7

8

9

10

Fatigue or Weakness

1

2

3

4

5

6

7

8

9

10

Fibrocystic Breasts

1

2

3

4

5

6

7

8

9

10

Fluid Retention

1

2

3

4

5

6

7

8

9

10

Food Cravings and/or Sensitivities

1

2

3

4

5

6

7

8

9

10

Gastro/Intestinal Problems

1

2

3

4

5

6

7

8

9

10

Hair Loss

1

2

3

4

5

6

7

8

9

10

Headaches

1

2

3

4

5

6

7

8

9

10

Heart Palpitations

1

2

3

4

5

6

7

8

9

10

Hot Flashes

1

2

3

4

5

6

7

8

9

10

Irritability

1

2

3

4

5

6

7

8

9

10

Memory/Concentration Issues

1

2

3

4

5

6

7

8

9

10

Mood Swings

1

2

3

4

5

6

7

8

9

10

Nervousness

1

2

3

4

5

6

7

8

9

10

Night Sweats

1

2

3

4

5

6

7

8

9

10

Painful Intercourse

1

2

3

4

5

6

7

8

9

10

PMS (females)

1

2

3

4

5

6

7

8

9

10

Sleep Disturbances

1

2

3

4

5

6

7

8

9

10

Vaginal Dryness (females)

1

2

3

4

5

6

7

8

9

10

Weight Gain

1

2

3

4

5

6

7

8

9

10

Other

1

2

3

4

5

6

7

8

9

10



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