H
EALTH AND
W
ELLNESS
Q
UESTIONNAIRE
J
AMES
J.
R
OMANO
,
MD
PERSONAL HISTORY
Smoking, how much, when ___________________________________________________
Recreational drugs __________________________________________________________
Alcohol, how much _________________________________________________________
Employed, by whom, what position ____________________________________________
Marital Status __________________________________________________
LIST
ALL
MEDICATIONS AND SUPPLEMENTS YOU TAKE
:
Y N and describe
Prescription Drugs__________________________________________________________
Vitamins__________________________________________________________________
Herbal Supplements including herbal teas________________________________________
Non-prescription or over-the-counter medications _________________________________
Recreational drugs, steroids ___________________________________________________
MEDICATION ALLERGIES
:_________________________________________________________
______________________________________________________________________________
E
XERCISE
P
ROFILE
List the types of exercise you currently perform and the frequency __________________________
N
UTRITION
I
NFORMATION
What is your height ______ weight ? ______ 1 year ago? ____ 5 years ago? ______Ideal? ________
Do you eat any of the following? (Circle only those that apply) :
Fried foods
Red meat
Vegetables
Diet Sodas
Alcohol
Caffeine
Fresh fruit
Butter
Bran
Sweets
Soy
Bread, Pasta, Rice
Do you floss your teeth every day? ___________ Do you use an ultrasonic toothbrush? ________
PLEASE CIRCLE ANY ADDITIONAL COSMETIC CONCERNS
:
Loose Skin (Face or Body) Forehead Lines Crows Feet
Decreased Lip volume Smokers Lines Laughs Lines
Dark Under Eye Circles Acne Pigmentation
Fine Lines or Wrinkles Scars Excessive Freckles
Do you have any areas of unwanted hair, pigmentation or blemishes, facial capillaries or leg veins?
Yes No If yes where? _________________________________________________
Any History of Laser or IPL treatments? Yes No If yes where?_____________________
Any History of Self Tanners/ or use of Tanning Beds? Yes No
126 Post Street, Suite 618
San Francisco, California 94108
415-981-3911
jim@jromano.com
www.jromano.com
