Unique IDMEDICAL HISTORY AND SCREENING FORM General InformationHiddenLocation HiddenViking Location VIKING ALTERNATIVE MEDICINE - CORPORATE Viking Chesterfield -132 Chesterfield Town Centre, Chesterfield MO 63005 TriMax Health and Fitness ParticipantFull Name ( Legal name) First Last Email HiddenPreferred Name (if different from above) HiddenSex Male Female HiddenMarital Status Single Married Divorced Widowed HiddenDate of Birth MM slash DD slash YYYY HiddenAge (years old)Hidden21st Birthday MM slash DD slash YYYY HiddenPhoneHiddenAlternate Phone NumberHiddenExists HiddenAddress Street Address Address Line 2 City ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPuerto RicoRISCSDTNTXUTVTVAWAWVWIWYAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan State ZIP Code HiddenBilling Address the Same as Shipping Address? Yes HiddenShipping Address Street Address Address Line 2 City ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPuerto RicoRISCSDTNTXUTVTVAWAWVWIWYAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan State ZIP Code HiddenHow did you hear about Viking Alternative Medicine?HiddenDriver License Number HiddenDriver License - State IssuedPlease choose stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginia[E]WashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoU.S. Virgin IslandsHiddenDate Expires MM slash DD slash YYYY Personal Medical HistoryPlease check all that apply: Alcoholism/drug abuse Asthma Cancer (please enter Cancer type below) Diabetes (please enter Diabetes type below) Emphysema (COPD) Heart Disease High Blood Pressure High Cholesterol Hypothyroidism/thyroid Disease Renal (kidney) Disease Migrane Headaches Stroke Other Other Condition Type of Cancer Type of Diabetes Surgeries/Hospitalizations Add RemoveDate of Last Physical Exam MM slash DD slash YYYY Height Weight Allergies to MedicationIf no allergies, please enter none. Add RemoveAllergies to Food Add RemoveMedication/Supplements Add RemoveWomen's HealthTotal Number of PregnanciesNormal DeliveriesC Section's Last Menstrual Period MM slash DD slash YYYY Duration Flow Heavy Regular Light Age of MenopauseLast Mamogram Last PAP exam Other Health IssuesSexually active Yes No Do you sleep well Yes No How many hours per night?Birth Control Method None Condom Pill Ring Patch Injection IUD Vasectomy Tubal ligation Do you exercise regularly Yes No How would you rate your diet? Good Fair Poor Review of SymptomsConstitution Activity change Appetite Change Chills Sweats Fatigue Fever Unexpected weight change Cardiology Chest pain Leg swelling Palpitations Head, Ears, Nose, and Throat Congestion Tinnitus (ringing in ears) Postnasal drip Rhinorrhea (runny nose) Ear pain Throat pain Facial swelling Hearing loss Voice change Nosebleeds Sinus pressure Gastrointestinal Abdominal Distention Abdominal pain Vomiting Blood in stool Constipation Diarrhea Nausea Respitory Apnea Chest tightness Choking Cough Shortness of Breath Stridor Wheezing Endocrine Cold Intolerance Heat Intolerance Increased hunger Increased urination Genitourinary Difficulty urinating Painful Urination Flank Pain Frequency Genital Sores Hematuria (blood in urine) Penile discharge Penile pain Penile swelling Libido issues Erectile issues Scrotal swelling Testicular pain Urgency Decreased urination Muscular Arthralgias Back Pain Gait Issues Joint swelling Muscle pains Neck pain Neck stiffness Skin Color change Pallor Rash Abnormal moles Neurological Dizziness Facial asymmetry Headaches Lightheadedness Numbness Seizures Syncope Tremors Weakness Hematologic Adenopathy Bruises Easily Bleeding Easily Psyciatric Agitation Behavior problems Confusion Nervous Anxious Depression Suicidal Ideas Hormone Imbalance SymptomsFemale Symptoms Hot Flashes Night Sweats Irregular periods Postmenopausal Weight gain Brain fog Difficult concentrating Decreased sex drive Vaginal dryness Hair loss/thinning Skin sagging/dryness Difficulty sleeping Irritability Decreased muscle mass Breast tenderness Headaches Male Symptoms Weight gain/excess abdominal fat Brain fog Difficulty concentrating Decreased sex drive Erectile issues Difficulty sleeping Decreased muscle mass Irritability Increased chest adiposity (fat) Signature(Required)I have read and understand all information contained in this document. I have answered all questions and supplied information about any conditions honestly and to the best of my ability.
