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LIFEFORCE MED Accepts Your Health Insurance We accept most major medical
health insurance plans for
diagnostic testing
Call us now at 847 905-9505!

Women consultation form

General Information

First Name*
M
Last Name*
Date of Birth (mm/dd/yyyy)
Street Address
City
State
Home Phone* (xxx-xxx-xxxx)
Cell Phone (xxx-xxx-xxxx)
Zip Code
Email Address*
Occupation
Employer
OK to communicate via E-mail?
Marital Status
Primary Care Physician Name
Phone Number
Street Address
City
State, Zip
Emergency Contact
Relationship to You
I hereby certify that the statements and answers given on this form are accurate to the best of my recollection and knowledge.*
Signed
Date

Medical History

Height
Current Weight
Desired Weight
Recent Changes in Weight (in number of pounds)
Gain
Lost
Waist Size
Goals for Age Management Medicine Consultation
Characters left: 200
Current Medical Conditions
Characters left: 200
How many times have you seen a physician over the last year regarding a health concern?
When was the last time you saw your physician? Was this visit for a specific illness or a general checkup?
How would you rate your health compared to that of individuals your own age?
Have you missed any time from work or were you unable to perform your normal activities due to illness?
If yes, how many days? Please explain circumstance.
Characters left: 200
Overall, how satisfied are you with your current health?
Please go over any details pertaining to the answer above.
Characters left: 200
Current Medications (doses and frequency)
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Current Nutrition/Herbal Supplements (please be as specific as possible)
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Allergies (to medications and non-medications)
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Hospital Admissions and Surgeries (please include year and illness/operation)
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Immunization

Please indicate year of last immunizations below.
Tetanus, Td
Pneumonia
Influenza
Hepatitis
Varicella

Dental Health (Please check all applicable)

Annual dental check ups
Annual teeth cleaning
Brush teeth at least once a day
Floss teeth once a day
Existing fillings
Unresolved dental problems
Other

Family History (Please check all applicable)

Heart Disease**
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Stroke
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Diabetes
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Cancer
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



High Blood Pressure
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Arthritis
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Liver Disease
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Mental Illness (Depression, Psychotic Disorder)
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Thyroid Dysfunction
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Asthma
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Lipid Disorder
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Osteoporosis
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Sleep Disorders (e.g. Sleep Apnea / Snoring)
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Alzheimer's
Not Applicable
Myself
Sibling
Parents Mother Father
Grandparent Maternal Paternal



Please provide details pertaining to your answer above.
Characters left: 200

Screening Tests

Dental Exam (mm/yy)
Results
Skin Exam (mm/yy)
Results
Colonoscopy (mm/yy)
Results
Bone Density (mm/yy)
Results

Female Hormone Symptom Profile

Please check any of the following symptoms which currently or periodically affect you.
Aches and Pains
Hair Loss - Pubic, Armpit and Body
Acne
Headaches
Anxiety
Heart Palpitation
Arthritis / Stiffness
Heat Intolerance
Bladder Symptoms
Hot Flashes
Blood Pressure - Low
Insomnia / Sleep Disturbances
Blood Pressure - High
Irritability
Body Temperature Low (Below 98 Degrees)
Mood swings
Breast Tenderness
Muscle Flabbiness / Decreased Size
Breast Size Increased
Muscle Weakness
Cold Intolerance
Nail Abnormality (Thick, Brittle, Ridged)
Cold Hands and/or Feet
Night Sweats
Constipation
Nipple Tenderness
Decreased Libido
Osteoporosis
Decreased Sense of Sexuality
Sensitive to Temperature Swings
Decreased Sexual Arousability
Sweating
Depression
Water Retention / Bloating
Diarrhea
Weakness
Drowsiness
Weight Gain
Dry Skin and/or Hair
Weight Loss
Temperature Swings
Wrinkles
Fatigue
Foggy Thinking
Food Cravings
Forgetfulness
Hair Loss - Scalp

Female Menstrual History

Pregnancies
Abortions
Miscarriages
Did you ever breast feed?
Age of first delivery?
Number of live births? Age
Age when you started menstrual period?
If menopausal, date of your last period?
Periods start every ___ days?
Number of days of cycle?
Periods
How do you feel a few days before and during your period?
Characters left: 200

Symptom Review (Check all that apply)

How do you feel today?
Fever
Runny Nose
Cough
Back Pain
Vomiting
Feet Pain
Chills
Sore Throat
Chest Pain
Neck Pain
Diarrhea
Numbness in arms
Fatigue
Headache
Pain on Urination
Nausea
Hand Pain
Tingling in arms or legs

Please explain further: Characters left: 2000

Sleep Habits

How many hours do you sleep a night?
Do you sleep soundly?
Do you feel refreshed upon waking in the morning?
How long does it take for you to fall asleep?
Are you using sleep aids?
How often and type?

Smoking Habits

Current or Past Smoker?
Yes
No
If yes, frequency and quantity or how long since quitting?
Alcohol use:
Type
Daily
Occasionally
Never
How Much
Exercise:
Daily
3-4 time/week
1-2 times/week
Never
*Required fields
Call
Please contact us for any questions regarding insurance, our services, scheduling and treatment plans.
Call us today at: 847 905-9505
You can also email us with your questions or to make an appointment. Send us your name, age, best
phone number and best time to call you and a professional member of our team will call or email you back:
Email to info@lifeforcemed.com
  • Our offices

  • MAIN OFFICE

    1 Northfield Plaza, Suite 470
    Northfield, IL 60093
    847 905-9505
    M-F 9:00 - 5:00

  • Satellite Offices

    1750 N. Kingsbury
    Chicago, IL 60614
    By Appointment Only

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