MEDICAL HISTORY QUESTIONNAIRE

Welcome to Boundless Health with Dr. Bret Scher! As we begin on our journey together to Health and Fitness, we first want to know more about you. Please take the time to fill out this medical history form prior to your first session. All information will be treated as protected medical information under HIPPA laws and will be shared only among Boundless Health practitioners. The form is extensive, but please try to make it as accurate and complete as possible. Your answers will help us design a comprehensive program that meets your individual needs.

May we send your Boundless Health records to your physician or primary health care provider and consult with them as necessary?

General Information

Occupation

MEDICAL HISTORY AND SCREENING FORM

Family Physician and/or Primary Health Care Provider:

Other Pertinent Physician or Health Care Provider

What is your goal for your participation in Our Wellness Program?

How many days per week can you commit to:

What are your current regular exercise activities, and how often do you do them?

Present Medical History

Check those questions to which you answer yes (leave the others blank).

Have you ever had or been treated for:

  • High blood pressure
  • High choletersol?
  • Pain in your chest or heart?
  • Thumping, racing or skipping of your heart?
  • Swollen ankles?
  • Heart trouble, an abnormal electrocardiogram (ECG or EKG) or heart attack ?
  • Cramps in your legs?
  • Difficulty breathing?
  • Shortness of breath before anyone else?
  • Trouble breathing when sitting still or sleeping?
  • Ligheatedness or dizziness
  • Fainting
  • Aortic aneurysm?
  • Valvular heart disease such as aortic stenosis?
  • Rheumatic Fever
  • Heart murmur
  • Varicose veins
  • Arthritis of legs or arms
  • Diabetes or abnormal blood-sugar tests
  • Phlebitis (inflammation of a vein)
  • Dizziness or fainting spells
  • Epilepsy or seizures
  • Stroke or TIA
  • Peripheral arterial disease (PAD)
  • Anxiety or depression
  • Anemia
  • Thyroid problems
  • Asthma
  • Abnormal chest X-ray
  • Other lung disease
  • Broken bones
  • Jaundice or gall bladder problems
  • Chronic cough?
  • Episode of coughing up blood?
  • Increased anxiety or depression?
  • Problems with recurrent fatigue, trouble sleeping or increased irritability?
  • Migraine or recurrent headaches?
  • Swollen, stiff or painful joints?
  • Pain in your legs after walking short distances?
  • Foot problems?
  • Back problems?
  • Recurrent heartburn,
  • Sromac or intestinal ulcers
  • Constipation or diarrhea?
  • Chrinc nausea or diarrhea
  • Unexplained weight loss?
  • A deep vein thrombosis (blood clot)?
  • A hernia that is causing symptoms?
  • Significant vision or hearing problems?
  • Recent change in a wart or a mole?
  • Glaucoma or increased pressure in the eyes?
  • Eye conditions such as bleeding in the retina or detached retina?
  • Cataract or lens transplant?
  • Laser treatment or other eye surgery?
  • Significant orthopedic injuries?

Have you had any prior surgeries? Please list.

Women only answer the following. Do you have:

  • Menstrual period problems?
  • Significant childbirth - related problems?
  • Urine loss when you cough, sneeze or laugh?
  • Prior C-section or hysterectomy

Medications and Supplements

(if none, please type in none)

Family Medical History

Have you or your first degree blood relatives had any of the following?

Check those to which the answer is yes (leave other blank).

  • Heart attacks under age 50
  • Strokes under age 50
  • Sudden unexplained death
  • Congenital heart disease (existing at birth but not hereditary)
  • Heart operations
  • Obesity (20 or more pounds overweight)

Smoking

Have you ever smoked cigarettes, cigars or a pipe?

  • Yes
  • No

(If no, skip to diet section)

SLEEP

STRESS

Diet

Are you sensitive or intolerant to Gluten? Dairy? Any other types of food?

How many glasses of water per day do you drink?

Other fluids?

What type of water filter do you use?

Approximately how many alcoholic beverages per week do you drink?

At any time in the past, were you a heavy drinker (consumption of six ounces of hard liquor per day or more)?

  • Yes
  • No

Do you drink caffiene? If yes, how much per day?

Do you eat differently on weekends as compared to weekdays?

  • Yes
  • No

Please list a sample days food intake:

858-799-0980Dr Bret Scher