Terese S. Harris, M.D., F ACOG

Name: (First) ________ Middle Int: _ _ (Last) _____________ _

Name Preferred: _________ Social Security Or Driver Lie.#: __________ _

Street Address: _______________________________ _

City: ______________ State: ____________ Zip: ______ _

Home Phone: ___________ Cell Phone: ________________ _

E-Mail:-----------------------------------

Date Of Birth: _____ __ Age: _____ _ Marital Status: __ S __ M __ D_W

Employer Name: _____________ Work Phone: ___________ _

Employer Address: ______________________________ _

State: ____ Zip: ____ What kind of work do you do? ______________ _

Spouse Name: _______________ Cell Phone: _____________ _

Spouse Employer: _______________ Work:#: ____________ _

Employer Address: ____________________ City: _____ State: __

Spouse's Social Security#: _________________________ _

Emergency Contact: ______________ Relationship: ___________ _

Emergency Phone: ___________ _

What is the reason for your visit today: ______________________ _

What result would you like to obtain: _______________________ _

I understand that I am directly responsible for all the charges incurred for services regardless of insurance

coverage.

Signed: _____________________ Date: . _________ _

Terese S. Harris, MD, FACOG

369 San Miguel Drive

Suite 235

Newport Beach, CA 92660

MALE MEDICAL HISTORY FORM

Patient information:

Name: _______________ Birth date: _________ _

Primary Care Doctor _________________________ _

What is your goal for today's visit?

Medical Conditions/Diseases. Please check all that apply to you.

Heart disease (congestive heart failure)

High cholesterol or lipids (Hyperlipidemia)

High blood pressure (Hypertension)

Cancer

Ulcers (stomach, esophagus)

Thyroid disease

Hormonal related issues

Blood clotting problems

Lung Conditions (asthma, COPD, etc ... )

Diabetes

Arthritis or joint problems

Depression

Epilepsy

Headaches/migraines

Eye disease (Glaucoma, ECT ... )

Other: Please list __________ _

Surgeries:

1.

2.

3.

4.

5.

6.

Date Surgery

Prescription Medications:

Complications

Please list prescription medications you are currently using. Be sure to include any mail order or

physician samples you are receiving.

Medication: Dose: Times a Day: Doctor:

Over The Counter (OTC) Medications:

Please circle all products that you use occasionally or regularly:

Nutritional/natural supplements: Please identify and list the products you are using.

Vitamins (multiple or single vitamins such as B Complex, E, C, Beta carotene):

Minerals (Calcium, magnesium, chromium, colloidal minerals)

Herbs (Ginseng, Ginkgo Biloba, Echinacea, herbal teas, tinctures, remedies)

Enzymes (digestive formulas, papaya, Bromelain, Coenzyme QlO)

Nutrition/protein supplements (Shark cartilage, protein powders, amino acids, fish oils)

Others ( Glucosamine)

Allergies: Please check all that apply:

Penicillin Dye Allergy

Codeine Nitrate Allergy

Sulfa Drug Pet Allergy

Morphine Seasonal Pollen

Aspirin None

Food Allergy Other

Please describe the allergic reaction you experienced and when it occurred: _________ _

Lifestyle Information:

Are you: Married Single Divorced Widowed (please check one)

If yes how often/how much

Tobacco (smoke, chew or snuff)

Alcohol (beer, wine or hard liquor)

Caffeine (cola drinks, tea or coffee)

Occupation __________________ _

IMPAIRMENTS: Check if you have any of the following

___ Physical Impairments ___ Visual Impairment ___ Hearing Impairment

EXERCISE: Do you exercise regularly? ___ Yes ___ No

If yes, describe your routine and how often: _______________ _

STRESS MANAGEMENT: Do you practice stress management techniques? __ Yes __ No

If yes, describe what and how often: _______________________ _

Have you experienced any of the following symptoms recently? Please check the number that best describes your experiences, with one being extremely mild and five being extremely severe.

Sleep disruptions 1 2 3 4 5

Irritability 1 2 3 4 5

Nervousness 1 2 3 4 5

Mood swings 1 2 3 4 5

Arthritis 1 2 3 4 5

Loss of recent memory/brain fog 1 2 3 4 5

Weight gain 1 2 3 4 5

Decreased sex drive 1 2 3 4 5

Depression 1 2 3 4 5

Fluid retention 1 2 3 4 5

Headaches 1 2 3 4 5

Hair loss 1 2 3 4 5

Harder to reach climax 1 2 3 4 5

Bladder symptoms 1 2 3 4 5

Other: explain 1 2 3 4 5