HiddenNP Reference Date MM slash DD slash YYYY MEDICAL 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) HiddenGender Male Female HiddenMarital Status Single Married Divorced Widowed HiddenDate of Birth MM slash DD slash YYYY Age (years old)Hidden21st Birthday MM slash DD slash YYYY HiddenPhoneHiddenAlternate Phone NumberHiddenExists HiddenAddress Street Address Address Line 2 City ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHPuerto RicoOKORPAPRRISCSDTNTXUTVIVTVAWAWVAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanWIWY State ZIP Code HiddenBilling Address the Same as Shipping Address? Yes HiddenShipping Address Street Address Address Line 2 City ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHPuerto RicoOKORPAPRRISCSDTNTXUTVIVTVAWAWVAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanWIWY 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 History(Required)Please 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(Required) MM slash DD slash YYYY Approximate date is acceptable if you cannot remember the exact date.Height(Required)4 Feet5 Feet6 feet6 feet7 FeetHeight (inches)(Required)0 inches1 inch2 inches3 inches4 inches5 inches6 inches7 inches8 inches9 inches10 inches11 inchesWeight(Required) Allergies to Medication(Required)If no allergies, please enter none. Add RemoveAllergies to Food(Required)If no allergies, please enter none. Add RemoveMedication/Supplements(Required)If no medication or supplements, please enter none. Add RemoveWomen's HealthTotal Number of Pregnancies(Required)Normal Deliveries(Required)C Section's(Required) Last Menstrual Period(Required)Start Date MM slash DD slash YYYY Duration(Required)Approximate number of days Flow(Required) Heavy Regular Light Age of Menopause(Required) Last Mamogram(Required) Last PAP exam(Required) Other Health IssuesSexually active(Required) Yes No Do you sleep well(Required) Yes No How many hours per night?(Required)Birth Control Method(Required) None Condom Pill Ring Patch Injection IUD Vasectomy Tubal ligation Do you exercise regularly(Required) Yes No How would you rate your diet?(Required) Good Fair Poor Review of SymptomsConstitution(Required) Activity change Appetite Change Chills Sweats Fatigue Fever Unexpected weight change NONE OF THE ABOVE Cardiology(Required) Chest pain Leg swelling Palpitations NONE OF THE ABOVE Head, Ears, Nose, and Throat(Required) Congestion Tinnitus (ringing in ears) Postnasal drip Rhinorrhea (runny nose) Ear pain Throat pain Facial swelling Eighth Choice Hearing loss Voice change Nosebleeds Sinus pressure NONE OF THE ABOVE Gastrointestinal(Required) Abdominal Distention Abdominal pain Vomiting Blood in stool Constipation Diarrhea Nausea NONE OF THE ABOVE Respitory(Required) Apnea Chest tightness Choking Cough Shortness of Breath Stridor Wheezing NONE OF THE ABOVE Endocrine(Required) Cold Intolerance Heat Intolerance Increased hunger Increased urination NONE OF THE ABOVE Genitourinary(Required) 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 NONE OF THE ABOVE Muscular(Required) Arthralgias Back Pain Gait Issues Joint swelling Fifth Choice Muscle pains Neck pain Neck stiffness NONE OF THE ABOVE Skin(Required) Color change Pallor Rash Abnormal moles NONE OF THE ABOVE Neurological(Required) Dizziness Facial asymmetry Headaches Lightheadedness Numbness Seizures Syncope Tremors Weakness NONE OF THE ABOVE Hematologic(Required) Adenopathy Bruises Easily Bleeding Easily NONE OF THE ABOVE Psyciatric(Required) Agitation Behavior problems Confusion Nervous Anxious Depression Suicidal Ideas NONE OF THE ABOVE Hormone Imbalance SymptomsFemale Symptoms(Required) 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 NONE OF THE ABOVE Male Symptoms(Required) Weight gain/excess abdominal fat Brain fog Difficulty concentrating Decreased sex drive Erectile issues Difficulty sleeping Decreased muscle mass Irritability Increased chest adiposity (fat) NONE OF THE ABOVE HiddenSignatureI 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.Please check to indicate your approval.(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.Name First Last
