New Patient Med History | Sachs Longevity Strategy

Patient Information

Patient's Name

Age

Date of Birth

Date of Visit

Previous Physician

Phone

Fax

Medical History

Chief Complaint(s): List the problems which have led you to seek medical help and approximately when they began.

Problem	Onset Date (MM-DD-YYYY)	Action

General Health and Habits

Characterize your present health status

ExcellentAveragePoor

Exercise

Do you exercise regularly?

YesNo

Type of exercise

Smoking

Do you smoke?

YesNo

Nutrition

Vitamin/Mineral Supplements

Weight 10 years ago (lbs)

Weight 5 years ago (lbs)

Current Weight (lbs)

Your appetite

ExcellentGoodFairPoor

Are there foods you avoid for health reasons?

Alcohol/Beverages

Drinks per day

Drinks per week

Did you formerly drink alcohol but have permanently stopped?

YesNo

Caffeinated beverages per day (coffee, tea, cola)

Past Medical and Surgical History

List chronologically all the surgery you have had, indicating the nature of each operation and where and when it was done. Be accurate and complete.

Operation	Hospital and City	Date (MM-DD-YYYY)	Action

Current Medications

Allergies

Family History

Past Medical Illnesses and Hospitalizations

List any serious illnesses, injuries, or hospitalization in chronological order:

Have you ever been seriously injured? (Please give details and dates)

Review of Systems

Answer all questions. If you do not know the answer or do not understand the question, insert a question mark. LEAVE NO BLANKS!!!

RESPIRATORY

Condition	NO	YES, When?
Pneumonia
Severe Bronchitis
Pleurisy
Tuberculosis (Skin Test)
Tuberculosis (Infection)
Asthma (wheezing)
Chronic Bronchitis
Emphysema
Other Lung Trouble
Exposure to dust/fumes
Trouble Breathing
Excessive Snoring
Chest Pain
Abnormal Chest X-Ray
Coughed up Blood
Regularly Have Cough
Get Chest Colds Often

DIGESTIVE

Condition	NO	YES, When?
Poor Appetite
Trouble Swallowing
Heartburn
Regurgitation of food
Regurgitation of Bile
Nausea/Vomiting
Abdominal Pain
Constipation
Diarrhea
Change in Bowels?
Hiatal Hernia
Esophageal Hernia
Duodenal Ulcer
Gastric Ulcer
Blood in Stool
Positive Stool Cards
Yellow Jaundice
Liver Trouble
Hepatitis
Gallbladder Trouble
Diarrhea/colitis
Diverticulitis
Parasitic Infection
Hernia
Digestive Disease

CIRCULATORY

Condition	NO	YES, When?
Chest Pain
Heart Trouble
Heart Attack
Angina Pectoris
High Cholesterol
High Blood Pressure
Blackouts
Racing of Heart
Rheumatic Fever
Heart Failure
Abnormal EKG
Ankle Swelling
Take Water Pills-Past?
Take Water Pills-Now?

ENDOCRINOLOGY

Condition	NO	YES, When?
Hormone Problems
Thyroid Disease
Diabetes
Osteoporosis

CUTANEOUS (SKIN)

Condition	NO	YES, When?
Skin Rashes
Skin Cancer

URINARY

Condition	NO	YES, When?
Kidney Disease
Nephritis
Protein in Urine
Albumin in Urine
Kidney Stones
Urinary Infection
Prostate Trouble
Syphilis
Gonorrhea
How Many Times Do You Urinate At Night?
How Many Times Do You Urinate During Day?

OBSTETRIC & GYNECOLOGICAL

Condition	NO	YES, When?
Breast Tumors
Breast Cysts?
Other Breast Disease?
# of Times Pregnant?
Miscarriages?
Last Pap Smear?
Had an Abnormal Pap?
Still Menstruating?
Your Last Period?
The One Before?
# of Live Births?
Do You Ever Bleed (spot) between Periods?
Do You Bleed After Intercourse?
What age did you begin to menstruate?
Have you had toxemia?
Have you had a hysterectomy?
Taking birth control pills?
How many days do your periods last?
Are your periods regular?
Are your periods heavy?
Length of cycle?

NEUROLOGICAL

Condition	NO	YES, When?
Neurological disease
Frequent headaches
Recurrent headaches
Loss of consciousness
Convulsions
Seizures
Head Injury
Stroke
Paralysis
Muscular weakness
Tremor
Abnormal movements
Difficulty in coordination
Difficulty in walking
Difficulty in speaking
Double vision
Loss of vision
Difficulty with memory
Dizziness

MOOD

Condition	NO	YES, When?
Experiences severe anxiety, panic or phobias?
Found it hard to concentrate?
Felt unable to enjoy your usual activities?
Had a weight change or eating disorder?
Had insomnia or excessive daytime sleepiness?
Been involved with domestic violence?
Felt depressed?
Thought yourself undeserving or worthless?
Felt excessively fatigued?
Had a nervous breakdown?
Under psychiatric care?
Had a drug or alcohol problem?
Would you like a consultation with a mental health professional?

SPECIAL SENSE

Condition	NO	YES, When?
Glaucoma
Other major eye disease
Deafness
Abnormal noises in the ear

IMMUNIZATIONS/VACCINES

ALLERGY & IMMUNOLOGY

Additional Information

Current Allergies to Medications/Food/Other

Any Additional Information You Would Like to Provide

Dates of Previous Testing-Important Information!

Test/Procedure	When/Details
Last Chest X-Ray
Last EKG
Last Mammogram
Last Pap Smear
Last Colonoscopy
Last PSA
Last Bone Density
Last Cologuard
Last GRAIL/Galleri Multi-Cancer Screen
Last Whole Body Screening MRI

Personal History

Where were you born?

Have you ever lived or traveled extensively abroad?

YesNo

What is your occupation?

Do you enjoy your work (or retirement)?

What is the highest level of education you have attained?

What inhaled chemicals or particles are you exposed to at your place of work?

Areas You Have Lived (Chronologically)

Area	Dates	Action

Past Occupations (Chronologically)

Occupation	Dates	Action

Family History

Have any of your blood relatives had the following?

Diabetes (Who)

Migraine (Who)

Allergies (Who)

Alcoholism (Who)

Heart Attack (Who)

Cancer/Type (Who)

Seizures (Who)

Epilepsy (Who)

Blood Disease (Who)

Psychiatric (Who)

Suicide (Who)

Kidney Disease (Who)

High Blood Pressure (Who)

Obscure Disease (Who)

Abnormal Bleeding (Who)

Clotting Disorder (Who)

Disease which "runs in the family"

Family Health Information

Relation	Age if Alive	Age at Death	Status of Health or Cause of Death
Mother
Father
Spouse
Siblings
Children

Form Completion

Patient Signature

Date (MM-DD-YYYY)

Condition	NO	YES, When?
Muscle Pain
Back Pain
Joint Pain
Joint Swelling
Gout
Diagnosed with Arthritis?
Diagnosed with Rheumatism?

Condition	NO	YES, When?
Anemia?
Bleeding?
Bruising Tendency?
Cancer?
Tumor?
X-Ray or Radiation Treatment?
Do you practice breast or testicular self exam?

Condition	NO	YES, When?
Tetanus-Diphtheria
Pneumococcal Pneumonia (Pneumovax)
Influenza (Flu)
COVID Vaccine
RSV
MMR
Chickenpox
Shingles
HPV
Hepatitis A
Hepatitis B
Meningococcal
Hib
Mpox
Other Vaccine(s)

Condition	NO	YES, When?
Asthma?
Eczema or other skin problems?
Hay fever or stuffy nose/sinuses?
Reaction to penicillin?
Reaction to aspirin?
Reaction to any other drug?
Rubella (German Measles) status?

Medical History Form

Patient Information

Medical History

General Health and Habits

Exercise

Smoking

Nutrition

Alcohol/Beverages

Past Medical and Surgical History

Past Medical Illnesses and Hospitalizations

Review of Systems

RESPIRATORY

DIGESTIVE

CIRCULATORY

ENDOCRINOLOGY

JOINTS

CUTANEOUS (SKIN)

URINARY

OBSTETRIC & GYNECOLOGICAL

HEMATOLOGY & ONCOLOGY

NEUROLOGICAL

MOOD

SPECIAL SENSE

IMMUNIZATIONS/VACCINES

ALLERGY & IMMUNOLOGY

Additional Information

Dates of Previous Testing-Important Information!

Personal History

Areas You Have Lived (Chronologically)

Past Occupations (Chronologically)

Family History

Have any of your blood relatives had the following?

Family Health Information

Form Completion