Patient Medical History Form (Page 5 of 5) in pdf

Patient Medical History Form Page 5

30. Typical Breakfast

Typical Lunch

Typical Dinner

Time eaten:

Where:

With whom:

31. Describe your usual energy level:

32. Activity Level: (answer only one)

Inactive no regular physical activity with a sit-down job.

Light activity no organized physical activity during leisure time.

Moderate activity occasionally involved in activities such as weekend golf, tennis, jogging,

swimming or cycling.

____Heavy activity consistent lifting, stair climbing, heavy construction, etc., or regular

participation in jogging, swimming, cycling or active sports at least three times per week..

Vigorous activity participation in extensive physical exercise for at least 60 minutes per

session 4 times per week.

33. Behavior style: (answer only one)

You are always calm and easygoing.

You are usually calm and easygoing.

You are sometimes calm with frequent impatience.

You are seldom calm and persistently driving for advancement.

You are never calm and have overwhelming ambition.

You are hard-driving and can never relax.

34. Please describe your general health goals and improvements you wish to make:

This information will assist us in assessing your particular problem areas and establishing your medical

management. Thank you for your time and patience in completing this form.

Patient Medical History Form Page 5