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Positive Health Guide

The human body is a form complete in its own                                                                          synergistically fluid with other life forms, 
                                                                      As well as itself.
©1992 Karen Myers Cobb

This is a copyright protected health history form designed  to convert a standard medical history into a positive health guide. Use this health guide as a tool to focus your own thought  processes so that you may better direct your own health care and fitness level. Condense your health concerns regarding  your own body for better communication with healthcare                   professionals on a single page, if possible;  if you have  multiple medical situations, as many of us do, add additional paper, as necessary. 
Health   (List top three health concerns)

Physical Fitness (List top three fitness priorities)

Life Performance 
   (List top three accomplishment goals for your body)

This includes activities in which you participate for                                                                                  sport, game, fitness and fun; this becomes important                                                                              when we diminish healthful activities.

                                    Fitness History
  adolescence: ________________________ None____
  adult: ______________________________ None____

                                                             (check, if applicable)

            weight currently ________#,  ideal_________ #                                                  

Attempts to change body weight up or down:
   This includes body building, fitness training, weight loss programs, gastric bypass, 12 step programs, anorexia, bulimia, steroid administration…

                                    Medical History
                                      (please circle)

Head           Headache                 teeth              sinus

              migraine, cluster    grind teeth at night     cancer

Neck      Thyroid         carotids        parotid glands

            parathyroid          cancer

Heart      Chest pain    Coronary  Heart Disease     heart attack      

             vascular disease  valve disease    stent       cancer     high cholesterol         

Lungs  ? smoke  Y  N  PPD ______ ? quit   Y  N     asthma      COPD              cancer

Stomach   ulcer   diarrhea   constipation   gas  

Bloody stool     black stool      vomiting      cancer

Liver      hepatitis     enlarged    cancer

Spleen     enlarged     removal    cancer 

Bone     osteoporosis   arthritis    joint replacement    cancer 

Other:___________________________________                                                                                         Back pain/ Cancer/ Diabetes/ Hypertension/ Obesity/ Osteoporosis/ Stroke 

                                    Lab tests

Blood Pressure: ___/___

AM Fasting Blood Sugar: ________


              HDL/LDL: _______     

Heart Rate:      Now _______      

  After 1 flight stairs _______
Recovery time back to resting____:______ 

                                 Lab tests

        Cholesterol: ______ Blood Pressure: ____ 

         Heart Rate: ______ Blood Sugar: ________


Soft tissue: ____________________________________________
Bone: _________________________________________________
Accident: ______________________________________________
Trauma: _______________________________________________

                                 Family History

(Please circle) Chest pain/Coronary Heart Disease/Back pain/ Cancer/ Diabetes/ Hypertension/ Obesity/ Osteoporosis/ Stroke


                                   Environmental History       
List every location of residence or work since birth.                                                                                       If pertinent, also list pre-/perinatal health concerns for you                            ___________________________________________

                                                Habits                                                                                                               (please fill out to the best of your ability)
  Glasses, cc or ounces, of water per day: _________
  Alcohol: glasses or bottles per day or week:______

  Alcohol: Glasses or bottles per day or week ______

  Smoke?     Y     N                 ? Quit   Y    N

  PPD:  Then ______     Now_______ 

  Stress: __________/10 during a typical day

  Stress:  6 months ago ____   /10 Now_________                                                                                                                     During a typical day, rate your stress on a scale of 0-10                                                                            Zero:  No physical or emotional discomfort  
Ten: the most physical or emotional pain that you can describe for yourself
               Meditate?:    Y       N
               Pain killers?:   Y        N   name___________
 Sleep:   _________     hours per night
 Seat belt?       Y      N     Car phone headset?   Y    N

Meals per day: 1    2    3    4    5    6

Portions per day of                                                                                                                                   Protein (chicken, fish or red meat): ____________beans:___  nuts:___
Complex Carbohydrates (fruits/veggies): ____________
Simple Carbohydrates (bread, bagel, chips, popcorn):___________
   bananas____ apples____ orange_____ melon_____
Fat (measure in TBSP/TSP) butter/oil_____ fried food # _____                                                               peanut butter ____chips /cheese /milk / scones: _______
Please complete this form for your healthcare provider;                                                                              This information is not helpful if it is not in your healthcare provider's hands and composed by you in your own words...