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“Foundation Mapping” (Health Screen Questionnaire):
Medical History
Do you have any current or past medical conditions? (e.g., hypertension, diabetes,
asthma, autoimmune disease, cancer, etc.)
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Have you ever had surgery or other medical procedures?
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Have you ever been hospitalized (other than for surgery)?
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Are you currently taking any prescription medications?
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Are you currently taking any over-the-counter medications or supplements?
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Allergies
Do you have any medication allergies?
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Do you have any other allergies (food, environmental, latex, etc.)?
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Family History
Please indicate any major health conditions among first-degree relatives – parents,
siblings, children.
Heart disease (before age 60)?
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Stroke?
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Diabetes?
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Cancer?
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If yes, what type?
Autoimmune disease?
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Mental health disorders (depression, anxiety, bipolar, etc.)?
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Other significant hereditary conditions (please specify):
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Social History
Tobacco use:
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Tobacco use:
A
Never
B
Current smoker (Packs/day: _____)
C
Former smoker (Quit date: _____)
Packs/Day or Quit Date if current/former smoker
Alcohol use:
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Alcohol use:
A
Never
B
Occasionally
C
Regularly (Drinks/week: _____)
Recreational drug use:
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Recreational drug use:
A
No
B
Yes (please list):
Exercise habits:
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Exercise habits:
A
Rarely
B
Occasionally
C
Regularly
Type and frequency of exercise:
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Nutrition habits (brief description):
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How would you describe your typical diet?
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Sleep habits:
Average hours per night:
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Sleep quality (scale of 1–10):
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Occupation:
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Hobbies / Interests:
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Musculoskeletal History
Have you had any previous or current musculoskeletal injuries (e.g., fractures,
tendonitis, arthritis, joint pain, back pain)?
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Do you currently experience any pain or discomfort that limits activity?
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Additional Information
Is there anything else you would like us to know before your first visit?
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Submit