Name (last, first, middle) *must be filled out

Address (please include city, state and zip) *must be filled out

Home Phone Number (include area code)*must be filled out

Work Phone Number

Social Security #

Birthdate (mo/day/yr)

Sex Male Female

Email address (screenname@ISP.com) *must be filled out (always double check to make sure email address is correct)

Password (six letters)

Race White Black Hispanic Asian Native American Other

Age

Primary Physician's name and phone number (optional)

Medications (name and dose)

Vitamins & Herbs No Yes If yes what

Allergies to Medication No Yes If yes what

Immunizations (tetanus, Flu , Hepatitis B vaccine … )

Past Medical History (list any diseases or illness you may have or had. Example: Asthma, HTN, Hepatitis, … )

Past Surgical History (List any surgeries you may have had. Example: Appendectomy, Hysterectomy, … )

Family History (List illnesses of 1^st degree relatives, e.g. Diabetes, Seizure disorder, … )

Mother living Yes No if No then age and cause of death

Father living Yes No if No then age and cause of death

Occupational History (list job and any occupational exposures e.g. None, Noise, Mercury, Asbestos,… )

Use of Recreational Drugs Yes No If yes are you still using? Yes No

Review of systems (List from head to toe any complaints or body system symptoms you may have e.g. Headache, chest pains, night sweats, …)

Height (without shoes):
3 4 5 6 7 Feet 0 1 2 3 4 5 6 7 8 9 10 11 Inches

Weight (without shoes):
Pounds

Blood pressure: (An example of a blood pressure reading is 120/80, with 120 being the systolic and 80 being the diastolic.)
Systolic Diastolic Do not currently know blood pressure

Total Cholesterol:
Cholesterol Do not know cholesterol

HDL cholesterol:
HDL Cholesterol Do not know HDL-cholesterol

Do you now or did you ever smoke cigarettes? (Mark only one response.)
No, I never have (go to question #8) Yes, I still smoke I quit 10 or more years ago I quit 5-9 years ago I quit 1-4 years ago I quit less than a year ago, but not within the past month I quit within the past month

How many cigarettes do/did you smoke per day on average?
6-14/day (around a half a pack) 15-24/day (around a pack) 25 or more/day

Do you use any of the following tobacco products at least once a day?
Pipe tobacco
Cigars
Smokeless tobacco
None of the above

On average, how many alcoholic beverages do you drink per week? (A bottle or can of beer, glass of wine, wine cooler, shot of liquor, or mixed drink is one drink.)

On the average, how close to the speed limit do you usually drive? Below or with in 5 mph over the limit 11-15 mph over the limit More than 15 mph over the limit

What is the curb weight of your vehicle lbs.

What percentage of the time do you wear a seat belt or shoulder harness while driving or riding in a car, truck, or van?
Rarely or never (less than 10%) About half of the time Always (more than 90%)

Compared with other people your age, how would you describe the amount of exercise you get, counting work and leisure activities?
Much more active Somewhat more active About average Somewhat less active Much less active Medical condition limits my activity

In an average week, how many times do you engage in vigorous (aerobic) physical activity? (Aerobic means work that lasts at least 20 minutes without stopping and that is hard enough to make you breathe heavier and your heart beat faster.)
Less than 1 time/week 1-2 times/week 3 or more times/week

Compared with other people your age, how do you rate your health?
Excellent Very Good Good Fair Poor

How many visits did you make to a doctor for any illness, injury, or preventive care in the past 12 months? (Do not include hospital stays.)

FOR MEN ONLY:

Women skip to Women's Only section
The following questions are necessary
for assessing cancer prostate  risk.

Do you routinely have your prostate examined by Digital Rectal Exam (DRE)? Yes No

Is there a family History of Prostate Cancer? Yes No

Do you have difficulties with urination (unable to produce a strong stream)? Yes No

Have you ever had your Prostate Specific Antigen (PSA) tested? Yes No, If yes what was the value?

Do you have any Erectile Dysfunction (ED) or Libido Problems?  Yes   No

FOR WOMEN ONLY:

Men skip to end
The following questions are necessary
for assessing breast cancer risk.

How many biopsies or needle aspirations of the breast have you had? History of ductal carcinoma or lobular carcinoma in situ?
None or Do not know 1 2 or more

How many of your blood relatives (mother, sisters, or grandmothers only) have had breast cancer?
None or Do not know 1 2 or more

How long has it been since your last mammogram (breast X-ray)?
Within the past year 1-2 years ago 3 or more years ago Never

How long has it been since you had your breasts examined by a physician or nurse?
Within the past year 1-2 years ago 3 or more years ago Never

Have you received instruction on how to properly examine your breasts?
Yes, and I perform once per month No or not sure

How long has it been since you had your last pap smear?
Within the past year 1-2 years ago 3 or more years ago Never

Based on the advice of a physician, are you currently taking hormone replacement therapy medication (e.g., menopause)?
Yes No

Comments:

Please include reason for visit, goals you wish to achieve, etc.

End of Questionnaire

Scroll down to bottom to submit.

Initial comprehensive office visits are usually $300 for a 1.5 to 2 hour session which includes a comprehensive physical examination.  Directed Consultations for a single problem start at $275 for new patients.  Established patients charges are typically $50 to 75 less.  Fee-for-service.  No insurance is filed.  Payment is requested upon rendering of services.

All prices are subject to change without notice.

Thank you!

Click the submit button and Dr. Saleeby will personally review your questionnaire.  You will be contacted by email within 48 hours. 
If not please call the office (912) 201-9464.