Health History Questionnaire Form - Jupiter Medical Center (Page 2 of 2) in pdf

MENTAL HEALTH HISTORY

Have you sought or are you currently under treatment/ counseling from a psychotherapist/ psychiatrist? _____

If yes, when, why, for how long?________________________________________________________________

ACTIVITY STATUS

Do you engage in a structured exercise program? Yes ___ No ___

If yes, # days a week____ # of minutes a day _____

My exercise includes:_______________________________________________________________________

PERSONAL HEALTH GOALS

Consider your own health goals and check the box next to the goals that are important to you

Improve strength

Gain weight/muscle

Improve flexibility

Reduce stress

Improve cardiovascular fitness

Stop smoking/drinking

Improve muscle tone and shape

Injury prevention

Lose weight/inches (circle one or both)

Continue to rehabilitate injury

Improve diet/eating habits

Increase energy

If your concern is osteoporosis:

Do you take hormone replacements?_________

If yes, what kind, and how much__________________

Date of onset of menopause?__________________Any history of fractures?________________________

Any family history of osteoporosis?______ If yes, what family member and what age___________________

Would you like to be on our mailing list? If so, check here _____

We would like you to complete our information before seeing the provider. If the client is a minor the

information must be completed by a parent or guardian. We are committed to providing the best care possible

to our client and we charge what is usual and customary for the services rendered. You are responsible for

payment in full at the time of service. We accept cash, checks, and all major credit cards. WE DO NOT

FILE ANY INSURANCE.

Please refrain from wearing scents or perfumes to respect the needs of all clients.

I HAVE READ THE ABOVE POLICY. I UNDERSTAND AND AGREE TO ALL OF ITS TERMS. I HEREBY

AUTHORIZE THE PROVIDER(S) OF THE WELLNESS SERVICES OF JUPITER MEDICAL CENTER TO

PERFORM TREATMENT AND RECORD REVIEW WHICH WILL BE DISCUSSED WITH ME AS

THEY DEEM APPROPRIATE.

_______________________________

___________________

Signature

Date

Comments:

C:\Users\e5911\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2OK09F39\HHQCC2010

Health History Questionnaire Form - Jupiter Medical Center Page 2