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We want to help you achieve your best health!  We welcome you to our office where we strive to be friendly, courteous and most of all -- informative. Our goal is to help you achieve your personal health goals. The benefits of optimal health via an anti-aging program at the BEST Program are immeasurable.  Please take a moment to complete this confidential application and medical history information, so that we may better address your anti-aging health needs.  Your application will be submitted to us via e-mail and will be ready for you to sign and complete when you arrive for your appointment.  If there are areas that you are unsure of, pass over them and we will address those questions when you are here in person.
* Required fields
 
1. About You
Today's Date:
Social Security #:
*Birthday:
Sex:
Family status:
*Name:
I like to be called:
*Home Address:
Apt./Condo #:
*City:
*State:
*Zip Code:
 
2. Telephone & Contact Info
*Home Phone:
*Work Phone:
Mobile Phone:
Email Address:
When is the best time to reach you during the day?
Where?
Specific Day?
Whom may we thank for referring you to our office?
Your Employer:
Occupation:

3. Medical History
*Name of Family Physician:
My current Physical Heath is:
Have you ever had any of the following?
Ulcers / Colitis
Rheumatic Fever / Artifical Valve / Murmer
Heart Disease / Defective Valves / Pacemaker
High or Low Blood Pressure
Kidney Problems
Diabetes
Tuberculosis
Malignancies (Cancer)
Asthma
Hay Fever / Allergies / Hives
Liver Disease or Jaundice
Thyroid Disorder
Epilepsy / Seizures / Fainting
Difficulties in Hearing or Vision
Alcohol/ Drug Use
Cigarettes
Stroke / TIA's
Sinus Trouble
Artificial Joints (Hip or Knee)
Anemia or Blood Disorder
Chronic infections (HIV, Herpes, Hepatitis, etc.)
Hormone use in the past
Carpal tunnel syndrome
Erectile dysfunction
Dimished libido
Depression or mood alterations
Fatigue
Poor exercise tolerance
Anxiety / Irritabily
Cold intolerance (feet / hands cold all the time)
Have you ever had adverse effects or reactions to:
Penicillin
Local Anesthetics (Novocaine, etc)
Latex
Any other drugs (if yes, please list)
 
*Are you now or recently been under the care of a physician?
 
  If yes, Please list why.
 
Current Medications:
Include Prescriptions and Over-The-Counter
Surgeries / Hospitalizations:
Family History:
Alive Deceased
Related
Health History
Mother:
Father:
Brother:
Sister:
Other:
ALL INFORMATION IS TRUE AND COMPLETE
TO THE BEST OF MY KNOWLEDGE

Thank you for completing this form.  It will enable us to help you more effectively. Please jot down any questions or special concerns you have and bring them with you at your appointment so we may address them.  We strive to be efficient and thorough in your evaluation and hope to get you started on your "BEST" program for anti-aging expeditiously.