Confidential Health History | Revitalize Health

Name*

First Last

Date

Phone*

Email*

At which Revitalize Health location are you a patient?*

Sugar Land
The Woodlands

EXERCISE & SLEEP HABITS

Do you currently exercise?*

Yes
No

What kinds of exercise do you perform and how often?*

What exercise equipment do you have at home?*

Examples: Exercise bands, hand weights, treadmill, elliptical, Bowflex, weight machine, etc.

Are you a member of a gym?*

Yes
No

I have lifted weights in the last:*

3 Months
6 Months
12 Months
I have not lifted weights in the last year

On average, how many hours of sleep do you get each night?*

Do you wake feeling rested?*

Yes
No

Is your sleep disturbed at the same time each night?*

Yes
No

At what time is your sleep typically disturbed?*

:

Do you have insomnia?*

Yes
No

Do you use sleeping aids?*

Yes
No

Do you snore?*

Yes
No

ENVIRONMENTAL, DETOX, & DENTAL INFORMATION

Do you adversely react to any of the following?*

(Check all that apply)

Monosodium Glutamate (MSG)
Dairy
Gluten (foods such as bread and pasta)
None of the above

Do you feel ill after consuming even small amounts of alcohol?*

Yes
No

Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Aspirin, Motrin, Tylenol, or acid-blocking drugs (Tagament, Zantac, Prilosec, etc.)?*

Yes
No

If yes, please list those prolonged/regularly used medications here:*

Which best describes your antibiotic usage?*

I take antibiotics more than 3 times a year
I take long-term antibiotics
My antibiotic use is infrequent
I do not use antibiotics

Which best describes your oral contraceptive usage?*

I have used oral contraceptives in the past
I presently use oral contraceptives
I have never taken oral contraceptives
Not applicable

I live or work near high tension power lines or transformers*

Yes
No

I sit in front of computers on a regular basis*

Yes
No

Do you have amalgam dental fillings?*

Yes
No

How many?

Have your amalgam fillings been removed?*

Yes
No

Approximately when were they removed?*

How many root canals do you have?*

How many crowns do you have?*

How many dental implants do you have?*

Do you use fluoride toothpaste?*

Yes
No

EATING HABITS

How many servings of the foods listed below do you consume daily?

(Enter a single numerical value)

Dairy

Fruits

Vegetables

Grains

Beans / peas

Meat, poultry, fish

Soy / tofu

Raw nuts / seeds

Roasted nuts / seeds

Cookies, cakes, chips, candy, etc.

List usual breakfasts*

List usual lunches*

List usual dinners*

How many meals do you eat each day?*

How often do you eat out per week?*

Do you microwave your food?*

Yes
No

Do you microwave in plastic?*

Yes
No

Do you skip breakfast?*

Yes
No

Do you graze on food during the day?*

Yes
No

Do you eat constantly weather hungry or not?*

Yes
No

Do you eat on the run?*

Yes
No

Do you eat fried foods?*

Yes
No

Do you drink water?*

Yes
No

How many ounces per day?*

Do you drink coffee/tea?*

Yes
No

What types(s) and how often?*

Do you drink soda?*

Yes
No

What types(s) and how often?*

Do you drink alcohol?*

Yes
No

What types(s) and how often?*

Do you crave chocolate?*

Yes
No

How often?*

What is your water source?*

(Well, distilled, filtered, bottled, tap, etc.)

What type of cookwear do you use?*

Aluminum
Non-stick
Cast iron
None of the above