Houstonian Medical Associates
Personal Assessment and Evaluation

Interested in a "personal" medical risk assessment with recommendations for your next physical exam? Simply complete and send us the questionaire. You will be contacted within 48 hours.
 
Date:      
First Name:   Last Name:
Mailing Address:   Email Address:
City:   Home Phone:
Zip Code:   Work Phone:
Age:   Sex: Female Male
History
Date of Last Exam:
Tests Performed:
Abnormal Tests:
Specific Problems or Concerns:
 
Has there been a family history or death due to Cancer, Heart Disease, stroke, diabetes, or hypertension?Yes No
If so, Please list age diagnosed, treatment and status of condition:
Self or Relative:   Age Diagnosed:   Diagnosis:   Status of Condition/or age of Death:
     
     
     
     
     
     
If personally diagnosed, Please list any treatment received:
Please list Prescription medications Past and Present:
 
Do you smoke? Yes No
 
List Examples of Foods that you eat:
Breakfast:
Lunch:
Dinner:
 
List types of exercize and frequency:
Type of Excercise: Frequency: