Patient Medical History Form | Revita Anti-Aging®

Personal Information

Name*

First Last

Sex*

Male
Female

Marital Status*

Single
Married
Divorced
Widowed

Social Security #

Date of Birth

Age

Revita Office Location*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Best Number to Reach You At*

Email*

Emergency Information

Emergency Contact Name*

Phone*

Email

Doctor Information

Family Physician

Phone

Gynecologist

Phone

Pharmacy

Phone

Social History

Occupation

Employer

Do you smoke tobacco products?*

Yes
No

How Often?

What Type?

Do you drink alcoholic drinks?*

Yes
No

How Much?

How Often?

Have you ever had any of the following?

An exam by a Cardiologist*

Yes
No

Excessive Bleeding / Bleeding Disorder*

Yes
No

Heart Attack or Heart Problems*

Yes
No

Rheumatic Fever*

Yes
No

Angina or Chest Pain with Exercise*

Yes
No

Stroke*

Yes
No

Heart Catheterization or Stress Test*

Yes
No

Sleep Apnea*

Yes
No

History of Asthma or Lung Problems*

Yes
No

Liver Disease/ Hepatitis*

Yes
No

Sickle Cell Anemia / Trait*

Yes
No

Skin Problems*

Yes
No

High Blood Pressure*

Yes
No

Multiple Sclerosis*

Yes
No

Diabetes*

Yes
No

HIV or AIDS*

Yes
No

Mitral Valve Prolapse*

Yes
No

Tuberculosis*

Yes
No

Macular Degeneration*

Yes
No

Cancer*

Yes
No

Seizure(s)*

Yes
No

Keloids*

Yes
No

Phlebitis*

Yes
No

Kidney Stones*

Yes
No

Sexually Transmitted Disease*

Yes
No

Thyroid Disorder*

Yes
No

Arthritis*

Yes
No

COPD*

Yes
No

ADD / ADHD*

Yes
No

High Cholesterol*

Yes
No

Chemical Dependency*

Yes
No

Crohns / Ulcerative Colitis*

Yes
No

Colitis*

Yes
No

Gout*

Yes
No

Fibromyalgia*

Yes
No

Other*

Yes
No

Describe any medical problems you need to discuss with the doctor:

Have you ever had cancer?*

Yes
No

If yes, please explain:

Medication & Food Allergies:

Please list all allergies to medications and your reaction below

Mental History

Have you ever been diagnosed with a mental illness?*

Yes
No

If yes, please explain:

Family History

Age

Father

Age at Death

Father

Cause of Death

Father

Hereditary Conditions

Father

Age

Mother

Age at Death

Mother

Cause of Death

Mother

Hereditary Conditions

Mother

Age

Sibling

Age at Death

Sibling

Cause of Death

Sibling

Hereditary Conditions

Sibling

Age

Sibling

Age at Death

Sibling

Cause of Death

Sibling

Hereditary Conditions

Sibling

Adopted?*

Yes
No

Health Maintenance

Date of Last Complete Physical Exam:

Date of Last Cholesterol Check:

Date of Last Colonoscopy:

Men Only

Date of Last PSA:

Date of Last Rectal Exam:

Women Only

Date of Last GYN Exam:

Date of Last Menstrual Cycle:

Date of Last Mammogram:

Date of Last Bone Density Test:

Medications and Supplements

Please list all your current medications and supplements with name, dosage, and how often. Also include vitamins and herbs that you regularly take.

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Medication Name

Dosage

How Often and How Long Taken

Previous Surgeries or Procedures

Please list your previous surgeries or endoscopy procedures

Surgery/ Procedure

Year

Surgery/ Procedure

Year

Surgery/ Procedure

Year

Surgery/ Procedure

Year

Hormone Usage History

If you are currently taking or have taken any types of hormones please list (include birth control pills or natural hormone cream both prescription and over the counter).

Brand

Milligrams

How often do you use them?

How long have you used them?

How did they affect you, and when discontinued?

Brand

Milligrams

How often do you use them?

How long have you used them?

How did they affect you, and when discontinued?

Brand

Milligrams

How often do you use them?

How long have you used them?

How did they affect you, and when discontinued?

Brand

Milligrams

How often do you use them?

How long have you used them?

How did they affect you, and when discontinued?

Have you ever had your levels of vitamins, minerals or antioxidants tested?*

Yes
No

If so, what deficiencies were found?

What are your biggest health goals?

Signature*

Today's Date*

Completed By

Today's Date*

Relationship

Referred By

Captcha

Personal Information

Emergency Information

Doctor Information

Social History

Have you ever had any of the following?

Medication & Food Allergies:

Mental History

Family History

Health Maintenance

Medications and Supplements

Previous Surgeries or Procedures

Hormone Usage History

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