Center for Integrative Health and Performance
  132 E. Broadway, Suite 332
Eugene, Oregon 97401
(P) 541-255-3205 (F) 888-864-3381
drperry@centerforIHAP.com
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Medical and Lifestyle History

Please complete the following questionnaire prior to your consultation with Dr. Perry.  All responses are confidential and are immediately directed to, and viewed solely by the physician.

If you prefer, you may download and print the Medical and Lifestyle History by clicking here. Please complete the form and bring with you for your initial consultation.

1. Patient name 2. Today's date 3. Full address and phone number, including cell phone/pager 4. E-mail address 5. Occupation 6. Age and date of birth 7. Height and weight 8. Gender 9. Marital status (S, M, D, W, cohabitate) 10. Primary physician name, address, and phone number 11. Date of last physical examination 12. List any past or current medical illnesses or diseases 13. List all past surgical procedures, including appendectomy, tonsillectomy, etc. 14. List all current medications and those within the past year 15. List all current nutritional supplements and those within the past year 16. List any food allergies Do any of your relatives have a history of the following (17-21) (if yes, please explain further)   17. Cardiovascular disease, including hypertension or coronary artery disease 18. Lipid disorders (high cholesterol, triglycerides, etc.) 19. Diabetes, thyroid, or other endocrine disorder 20. Cancers 21. Other family illnesses 22. How much do you smoke, or did you smoke in the past? 23. How much alcohol do you consume daily or weekly? 24. Do you use or have you used any illicit drugs, including marijuana?

25. Are you using or have you used anabolic hormones, including human growth hormone? 26. How many days per week do you exercise? How many minutes or hours is a typical session? 27. Describe your normal exercise routine. 28. Are you vegetarian or vegan? 29. What are your primary protein sources? 30. What are your primary carbohydrate sources? 31. What are your primary fat sources? 32. Do you consume caffeinated beverages? 33. Do you take a multivitamin? Questions pertaining to potential treatment:   (if yes, please explain quantity, length of time, and/or severity)   34. Have you experienced menopause? 35. Are you pregnant? 36. Are you currently nursing? 37. Do you have heat or cold intolerance? 38. Have you experienced muscle loss or wasting (sarcopenia)? 39. Decreased muscular strength? 40. Decreased sex drive? 41. Do you have difficulty achieving or maintaining an erection? 42. Do you awaken at night to urinate? 43. Experiencing decreased energy or endurance? 44. Thinning or loss of hair? 45. Unintentional weight gain or loss? 46. Difficulty falling asleep or remaining asleep? 47. Developed osteoporosis (loss of bone mass, brittle bones)? 48.  Is your overall mental attitude upbeat, steady or depressed?