Health History Questionnaire Step 1 of 7 14% NOTE: If you stop filling out the form and try to resume, your info will be lost! It is best to complete in one sitting. Deepa B Verma, MD, ABIHM 3165 N. McMullen Booth Rd, D-2 Clearwater, FL 33761 (p) 727.754.2936 (f) 727.754.2937 305 N Rome Ave, Tampa, FL 33606 (p) 813.565.1521 (f) 813.565.1522 Health History Questionnaire All material in this questionnaire is strictly confidential and will become part of your medical record. Please take time to fill this health history form out completely and be as detailed as possible. We appreciate your time and investment on your journey to wellness with Synergistiq.Today's Date:(Required) MM slash DD slash YYYY Name(Required) First Middle Last DOB:(Required) MM slash DD slash YYYY Age:(Required)Gender:(Required) Female Male Home Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Home Phone:(Required)Cell Phone:Work Phone:E-Mail(Required) Preferred Daytime Contact Phone:(Required) Home Cell Work Race/Ethicity:Employer:PCP Name & Phone Number:(Required)Names of Specialists (if any):Date of Last Physical:Referred By:This field is hidden when viewing the formMain Reason For Visit:What current symptoms do you have and when did it/they start?Hair lossWeight gainWeight lossSkin changes such as wrinkles, acne, hair growth on faceJoint painsDepression or anxietyAnger or frustrationChange in BMs or gut health issues (describe)Chest painsShortness of breathDizzinessBrain fogHigh blood pressure or low blood pressureInsomnia or sleep disturbancesLoss of appetiteDecreased muscle mass Past & Present Medical Conditions and Family History:Acid Reflux Self History Family History Alcoholism Self History Family History Allergies Self History Family History Anemia Self History Family History Anxiety Self History Family History Arthritis Self History Family History Asthma Self History Family History ADD/ADHD Self History Family History Bipolar Disease Self History Family History Cancer & Type of Self History Family History Cataracts Self History Family History Clotting Disorders Self History Family History Congestive Heart Failure Self History Family History Constipation Self History Family History Crohn's Self History Family History Dementia Self History Family History Depression Self History Family History Diabetes & Type Self History Family History Diarrhea Self History Family History Dizziness Self History Family History Drug Abuse Self History Family History Eating Disorder Self History Family History Eczema Self History Family History Fibromyalgia Self History Family History Glaucoma Self History Family History Gluten Sensitivity Self History Family History Gout Self History Family History Gallbladder disease Self History Family History Heart Attack/Angina Self History Family History Heart Valve Disorder Self History Family History High Blood Pressure Self History Family History High Cholesterol Self History Family History HIV Self History Family History Hyperthyroidism Self History Family History Hypothyroidism Self History Family History Immune Problems Self History Family History Infertility Self History Family History Insomnia Self History Family History Irregular Heartbeat Self History Family History Kidney disease/stones Self History Family History Liver Disease/Fatty Liver Self History Family History Lyme Disease Self History Family History Migraine Headaches Self History Family History Multiple Sclerosis Self History Family History Obesity Self History Family History Osteoporosis Self History Family History Peripheral Arterial Disease Self History Family History Psoriasis Self History Family History Schizophrenia Self History Family History Seizures Self History Family History Stroke Self History Family History Ulcers Self History Family History Where were you born?(Required)Do you travel internationally?(Required)How often do you travel internationally?(Required)When you travel, where do you go?(Required)Have you had(Required) Chicken Pox Measles Mumps No Have you had the CoViD vaccine and boosters? Which one?(Required) Pfizer Moderna J&J No Have you had any adverse health issues from that?(Required) Yes No Not Sure Are you adopted?(Required) Yes No Not Sure Is your mother(Required) Alive Deceased Unknown Age & Current Medical/Psych Problems(Required)Age at Death & Cause(Required)Is your father(Required) Alive Deceased Unknown Age & Current Medical/Psych Problems(Required)Age at Death & Cause(Required)Do you have siblings?(Required) No Yes Not Sure Are your siblings...(Required) Full siblings Half siblings Maternal Paternal Brother(s) (Full & Half), Age(s), Medical/Psych Problems(Required)Sister(s) (Full & Half), Age(s), Medical/Psych Problems(Required)Is your maternal grandmother (MGM) (Alive/Deceased?)(Required) Alive Deceased Unknown Cause of Death, Age, Medical/Psych Problems(Required)Is your maternal grandfather (MGF) (Alive/Deceased?)(Required) Alive Deceased Unknown Cause of Death, Age, Medical/Psych Problems(Required)Is your paternal grandmother (PGM) (Alive/Deceased?)(Required) Alive Deceased Unknown Cause of Death, Age, Medical/Psych Problems(Required)Is your paternal grandfather (PGF) (Alive/Deceased?)(Required) Alive Deceased Unknown Cause of Death, Age, Medical/Psych Problems(Required)Past Surgeries & Hospitalizations:1. Name/Reason/DiagnosisYear2. Name/Reason/DiagnosisYear3. Name/Reason/DiagnosisYear4. Name/Reason/DiagnosisYear5. Name/Reason/DiagnosisYear6. Name/Reason/DiagnosisYear7. Name/Reason/DiagnosisYear8. Name/Reason/DiagnosisYear9. Name/Reason/DiagnosisYear10. Name/Reason/DiagnosisYear11. Name/Reason/DiagnosisYear12. Name/Reason/DiagnosisYearCurrent Height(Required)Current Weight(Required)Are you aware of physician-regulated, pharmaceutical-grade supplements/nutraceuticals?(Required) Yes No Not Sure From where/whom do purchase them?(Required)Prescribed Pharmaceutical and/or Nutraceutical Medications & Dosages if Known:(Required)OTC Drugs/Vitamins/Supplements/Herbs & Dosages if Known:(Required)Have you ever used GLP-1s such as semaglutide or tirzepatide for weight loss?(Required) Yes No Not Sure Have you ever used phentermine?(Required) Yes No Not Sure Known Drug Allergies/Sensitivities:(Required)Known Food Allergies/Sensitivities:(Required)Known Environmental Allergies:(Required) Lifestyle Questions:Are you trying to lose weight(Required) No Yes Not Sure If yes, how many pounds?(Required)Highest weight(Required)Lowest weight(Required)Are you following a diet(Required) No Yes Not Sure If yes, type(Required) Doctor Prescribed Atkins Mediterranean South Beach Raw Food Vegan The Zone Vegetarian Weight Watchers NutriSystem Jenny Craig Macrobiotic Cookie Glycemic Index Other Do you practice fasting or intermittent fasting?(Required) Yes No Not Sure How many BMs daily and is it formed/regular?(Required)Do you exercise(Required) No Yes Not Sure If yes, what type of exercise?(Required)How many times per week?(Required)How many minutes per day?(Required)Have you ever been a member at a gym?(Required)Worked with personal trainer?(Required)Do you drink alcohol(Required) No Yes Not Sure What is the frequency? (E.g. daily, weekends, purely social)(Required)Are you dependent on alcohol?(Required)If so, for how many months/years?(Required)What is your preferred alcoholic beverage(s)?(Required)Have you ever used any recreational drugs in your life?(Required) No Yes Not Sure For how long and what types?(Required)Do you smoke?(Required) No, never I used to for this many years Yes, current use. Number of years smoked(Required)Do you vape?(Required) No, never I used to for this many years Yes, current use. Number of years vaped(Required)Do you smoke cigarettes?(Required) Yes No Not Sure Number of packs daily(Required)Smoked since age(Required)How many hours of sleep do you get?(Required)Is it refreshing/restorative?(Required)Do you take naps during the day(Required) No Yes Not Sure Do you wake up in the middle of the night(Required) No Yes Not Sure How many times and why?(Required)Have you ever been exposed to chemicals?Do you drink coffee?(Required) No Yes Not Sure If yes to drinking coffee(Required) Black Coffee Cream Only Sugar Only Cream and Sugar cups daily(Required)Do you drink tea?(Required) No Yes Not Sure What types of tea?(Required)What do you put in your tea?(Required)Do you drink soda?(Required) No Yes Not Sure Do you have a history of drinking soda? If so, for how many years?(Required)cups daily(Required)cups weekly(Required)What type of soda do you drink?(Required) Diet Regular Do you consume or have you ever consumed energy drinks?(Required) Yes No Not Sure Do you drink juice(Required) No Yes Not Sure cups daily and type(s)(Required)Do you use artificial sweeteners?(Required) No Yes Not Sure I use these types sweeteners:(Required)How many glasses of water do you drink daily?(Required)Type of water?What types of cravings do you have(Required) Sweet Salty Fatty Carbs Other What are your main sources of protein? (e.g. animal vs plant-based)(Required)How many fruits & vegetables do you eat daily?(Required)Types of fruitsHow often do you eat fast food or at a restaurant?(Required)How many meals do you eat daily?(Required)Are you aware of seed oils?(Required) Yes No Not Sure Do you consume seed oils?(Required) Yes No Not Sure Do you eat breakfast(Required) No Yes Not Sure If yes, what?(Required)Describe your lunch(Required)Describe your dinner(Required)Do you snack between meals?(Required) No Yes Not Sure If yes, what?(Required)Have you ever seen a therapist or life coach?(Required)What is your biggest gripe about healthcare?(Required)At what age did you feel your best? Or do you think it is yet to come?(Required)What do you enjoy most in life?(Required)What are you most scared of in life?(Required)What are your pet peeves?(Required)What are your hobbies?(Required)Are you religious? Spiritual? Both? Neither?(Required)Do you enjoy your job?(Required)Do you feel fulfilled in life?(Required)What are your life stressors?(Required)What is your sexual orientation?(Required)Have you ever been abused (physically, emotionally, sexually)?(Required)If you are in a relationship, is it healthy?(Required)Do you have emotional support?(Required)Who is in your household?(Required)Do you have pets?(Required)How would you describe your personality?(Required)Name 3 personal strengths(Required)Name 3 personal weaknesses(Required)What goals do you want to achieve in life?(Required)Have you ever considered aesthetic treatments for anti-aging?(Required)Are you interested in BHRT (bioidentical hormones) or peptides for anti-aging and regenerative health?(Required)Whether you are male or female, would you consider organic skin care?(Required)Are you interested in laser skin resurfacing or microneedling?(Required)For women, would you consider vaginal rejuvenation to improve intimacy and incontinence?(Required)Do you feel anti-aging and aesthetic treatments are important to feel refreshed and rejuvenated?(Required)Are you familiar with biohacking?(Required) Yes No Not Sure Are you interested in any of the following? EBOO Infrared sauna PEMF mat IV therapy CVAC pod Have you ever considered exosomes or PRF or neurotox (i.e Xeomin/Daxxify/Botox etc)(Required) Birth and Childhood QuestionsHow was your Mother's pregnancy with you?(Required)Was it a healthy pregnancy?(Required) No Yes Not Sure Did she take any pharma meds?(Required) No Yes Not Sure Did she drink alcohol? No Yes Not Sure Did she do drugs?(Required) No Yes Not Sure Was she depressed?(Required) No Yes Not Sure How old was she when she was pregnant with you?(Required)Were you born full-term or pre-term?(Required) full-term pre-term Were you born vaginally or via c-section?(Required) vaginally c-section If born via c-section, why?(Required)Were you breast-fed or formula-fed or both?(Required) breast-fed formula-fed both Did you have cow's milk or soy allergies in formula?(Required) Yes No Not Sure How was your childhood?: (Select all that apply)(Required) I was sick a lot I was seldom sick I was hospitalized Overall, I was healthy I took a lot of antibiotics I seldom took antibiotics I took a lot of steroids such as prednisone Describe any major incidents or illness you had.(Required) FOR FEMALES If this does not apply to you based on gender or age, you may skip the questions.How many times have you been pregnant total?Living childrenAbortionsMiscarriagesPre-termFull-termStillbornEctopic# C-sections# of Vaginal birthsAdopted childrenHave you ever been a surrogate?Have you tried IVF?Was it successful?Have you had a mammogram No Yes Not Sure Have you ever had a breast lump No Yes Not Sure Was the lump benign or malignant?Age of first periodDate of your last period Regular Irregular Heavy bleeding No Yes Not Sure Painful periods No Yes Not Sure # Days period lastsAre you sexually active No Yes Not Sure Are you satisfied No Yes Not Sure Vaginal dryness No Yes Not Sure Loss of libido No Yes Not Sure Loss of orgasm No Yes Not Sure Hot flashes/Night sweats No Yes Not Sure Urine leakage No Yes Not Sure Hair loss No Yes Not Sure Breast tenderness No Yes Not Sure Mood swings No Yes Not Sure Dry skin/wrinkles No Yes Not Sure Adult Acne No Yes Not Sure Food cravings No Yes Not Sure Sleep disturbance No Yes Not Sure Fatigue No Yes Not Sure Wear sunscreen/SPF products No Yes Not Sure FOR MALES If this does not apply to you based on gender or age, you may skip the questions.Loss of aggressiveness No Yes Not Sure Loss of libido No Yes Not Sure Loss of confidence No Yes Not Sure Difficulty achieving erection No Yes Not Sure Difficulty maintaining erection No Yes Not Sure Premature ejaculations No Yes Not Sure Performance anxiety No Yes Not Sure Loss of orgasm No Yes Not Sure Loss of masculinity No Yes Not Sure Irritability No Yes Not Sure Mood swings No Yes Not Sure Memory loss No Yes Not Sure Sleep disturbance No Yes Not Sure Breast enlargement/Tenderness No Yes Not Sure Abnormal penile discharge No Yes Not Sure Prostate problems No Yes Not Sure Skin/Hair problems No Yes Not Sure Fatigue No Yes Not Sure Increased abdominal girth No Yes Not Sure Loss of muscle tone No Yes Not Sure THANK YOU! BE HEALTHY. BE HAPPY. BE AWESOME(Required) I accept the Terms of Use * You're not done yet... you still have 1 more form to go!