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St. Luke’s ExecuHealth Pre-Physical Questionnaire
Thank you for choosing St. Luke’s ExecuHealth. This questionnaire will help your Lead Physician tailor a
comprehensive assessment most appropriate for you, more effectively assess your present and future
health concerns, and work with your ExecuHealth Manager to organize a highly efficient experience.
Please complete and submit this form to your ExecuHealth Manager via email or fax to 484-503-0901.
Date of Physical: ______________________________________________________________________
Full Name:
________________________________________________________________________
Home Address: _______________________________________________________________________
City: ___________________________________________ State: __________ Zip Code: _____________
Date of Birth: ________________________________________________________________________
Preferred Method of Communication:
❑ Phone
❑ Email
E-mail Address: ________________________________________________________________________
Phone Number(s): Please check preferred contact number
❑ Home: ___________________ ❑ Work: ___________________ ❑ Cell: ____________________
Employer:
________________________________________________________________________
Title:
________________________________________________________________________
Employer Address:
_________________________________________________________________
City: ____________________________________________ State: __________ Zip Code: ____________
Emergency Contact Person: ___________________________________________________________
Emergency Phone Number: _________________________ Relationship to Patient: ____________
How did you learn about ExecuHealth? ❑ TV ❑ Billboard ❑ Website ❑ Print Ad
Referred By: ________________________________ Other: __________________________________
Exercise Clothing: Pants Size: ________________ Shirt Size: _________________
PRESENT HEALTH STATUS
Please indicate your gender:
❑ Male
❑ Female
How would you assess your current overall health status?
❑ Excellent
❑ Good
❑ Fair ❑ Poor
How would you describe your health status over the past few years?
❑ Stable
❑ Improving
❑ Declining
How content are you with your current health status?
❑ Very Content ❑ Somewhat Content ❑ Disappointed ❑ Very Disappointed
2
Do you have a personal physician? If yes, please provide information below.
❑ Yes ❑ No
Physician Name:
___________________________________________________________
Physician Address:
___________________________________________________________
Physician Phone:
__________________________ Fax: ____________________________
Would you like a copy of your wellness report sent to your physician?
❑ Yes ❑ No
MEDICAL HISTORY
Did you have any childhood illnesses which resulted in ongoing abnormalities or may present future
health concerns (e.g., Polio with isolated weaknesses; Rheumatic Fever with heart valve damage, etc.)?
❑ Yes ❑ No
If yes, please explain: ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
As an adult, have you had a history of any significant medical illnesses, such as:
❑ Heart Disease
❑ Diabetes
❑ Lung Disease
❑ Lung Cancer
❑ High Cholesterol
❑ Unusual Infections
❑ High Blood Pressure
❑ Asthma
❑ Emphysema/COPD
❑ Shortness of Breath
❑ Other Illness / Cancer(s)
If yes, please explain: ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you been hospitalized for anything other than surgery?
❑ Yes ❑ No
If so, for what and when? ___________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please indicate any surgical procedures you have undergone, the surgeon, and when the surgery was
performed:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you experienced any injuries in the past that compromised any of your functionality?
❑ Yes ❑ No
If yes, please explain: ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3
Have you had any advanced diagnostic procedures (e.g., heart catheterization, CAT or MRI scans,
treadmill studies, etc.)?
❑ Yes ❑ No
If yes, please indicate the procedure(s), timeframe(s), and reason(s):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Are you able to walk and/or run on a treadmill?
❑ Yes ❑ No
Please indicate and list all prescription medications, over-the-counter medications, vitamins, and/or
herbal supplements you are taking. Include dosages, frequency, and any directions.
Please indicate the vaccinations you have received and when they were administered:
❑ Pneumonia
❑ Hepatitis A / B
❑ Tetanus (Td /
TdAP
❑ Shingles
(Zostavax)
❑ Influenza
Date:
Have you had any travel-related vaccinations (Typhoid, Yellow Fever, etc.)?
❑ Yes ❑ No
If so, please list these and the date(s) they were administered:
__________________________________________________________________________________
__________________________________________________________________________________
Do you have a history of any food or drug allergies (Iodine, Intravenous Contrast Dye)? ❑ Yes ❑ No
If yes, please identify the allergy and the reaction you experienced:
__________________________________________________________________________________
__________________________________________________________________________________
Are you allergic or sensitive to any smells, perfumes, lotions, ultrasound gel?
❑ Yes ❑ No
If yes, please identify the allergy and the reaction you experienced:
__________________________________________________________________________________
__________________________________________________________________________________
4
FAMILY HISTORY
Father
Mother
Siblings
Is your father living?
❑ Yes ❑ No
Is your mother living?
❑ Yes ❑ No
Do you have any siblings?
❑ Yes ❑ No
What age is he (or age at death)?
_____ years
What age is she (or age at death)?
____years
Please specify brother or sister and
their age (or age at death)?
____________________________
____________________________
____________________________
____________________________
____________________________
Please indicate if your father has
(had):
❑ Heart Disease
❑ Diabetes
❑ Lung
Disease/Emphysema/COPD
❑ Cancer
❑ High Cholesterol
❑ High Blood Pressure
❑ Serious Infections
❑ Other Illnesses
Please provide details:
Please indicate if your mother has
(had):
❑ Heart Disease
❑ Diabetes
❑ Lung
Disease/Emphysema/COPD
❑ Cancer
❑ High Cholesterol
❑ High Blood Pressure
❑ Serious Infections
❑ Other Illnesses
Please provide details:
Please indicate if your siblings have
(had):
❑ Heart Disease
❑ Diabetes
❑ Lung Disease/Emphysema/COPD
❑ Cancer
❑ High Cholesterol
❑ High Blood Pressure
❑ Serious Infections
❑ Other Illnesses
Please provide details:
5
SOCIAL HISTORY
Tobacco, Alcohol, Caffeine Use:
Tobacco Use
Alcohol Use
Caffeine / Other Drug Use
Do you currently use tobacco
products? ❑ Yes ❑ No
If yes:
What kind (cigarettes, cigars,
smokeless)? _________________
How many/much do you use daily?
_____________/day
How long? _____ years
If no:
Have you ever used tobacco
products? ❑ Yes ❑ No
If yes, when did you quit? _______
What type of tobacco products did
you use?_____________________
How many/much did you use daily?
________/day
How long did you use? _____ years
Have you been exposed to passive
smoking in a household or work
environment? ❑ Yes ❑ No
If yes, how long? ______________
Do you now drink or have you
previously drunk alcohol regularly?
❑ Yes ❑ No
Do you consume caffeine
regularly?
❑ Yes ❑ No
How many drinks do you consume
daily? __________/day
How many caffeinated drinks do
you consume daily?
_________/day
Do you think you have / had a
problem with drinking?
❑ Yes ❑ No
Do you think you are addicted to
caffeine?
❑ Yes ❑ No
Do/have you:
❑ want to quit?
❑ think you can quit?
❑ ever been able to quit?
Have you:
❑ felt the need to reduce your
alcohol consumption?
❑ felt upset by others criticizing
your alcohol consumption?
❑ felt guilty about your alcohol
consumption?
❑ had the need to drink when you
wake in the morning?
Have you ever:
❑ had caffeine withdrawal?
❑ had symptoms such as
headache?
❑ used any “recreational” / street
drugs?
If so, please explain:
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Occupation:
Previous Occupations
Dates of Employment
LIFESTYLE
General:
What is your marital status?
❑ Married ❑ Remarried ❑ Divorced
❑ Widowed
❑ Engaged
❑ Single
Are you satisfied in your current marital state?
❑ Yes ❑ No
Are there any sexually-related topics that you would like to discuss confidentially?
❑ Yes ❑ No
_____________________________________________________________________________________
Do you have children?
❑ Yes ❑ No
If yes, please list their birth year, gender and any medical issues:
__________________________________________________________________________________
__________________________________________________________________________________
Are you satisfied with your current work/life balance, lifestyle, and daily responsibilities? ❑ Yes ❑ No
How would you rate your level of stress?
❑ Low
❑ Somewhat Low
❑ Somewhat High
❑ Very High
Are you exposed to toxins, irritants, or allergens, etc. at home or work?
❑ Yes ❑ No
If yes, please explain: ________________________________________________________________
How many hours per week are you sedentary? ______________________________________________
Annually, how much vacation do you typically take? __________________________________________
When was your last vacation of one week or more in duration? _________________________________
How long in duration is your longest annual vacation? ________________________________________
Exercise:
How do you assess your current state of physical fitness?
❑ Poor
❑ Below Average
❑ Average
❑ Above Average
❑ Excellent
Do you partake in a regular exercise program/routine?
❑ Yes ❑ No
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If yes, what type of exercise? __________________________________________________________
If yes, how frequent and long in duration? _______________________________________________
What are your goals of this exercise program/routine? _____________________________________
If no, how long has it been since you exercised? __________________________________________
Do you participate in strenuous sports activities (running, biking, etc.)?
❑ Yes ❑ No
If yes, please describe: _______________________________________________________________
Would you like to place greater emphasis on exercise in the future?
❑ Yes ❑ No
If yes, list any specific goals you would like to achieve: _____________________________________
__________________________________________________________________________________
If yes, list areas of your body, if any, for which you would like to focus: ________________________
__________________________________________________________________________________
Please indicate how much time is available weekly for you to devote to reaching your fitness goals.
Number of sessions/week: ___________________________________________________________
Minutes per session:
___________________________________________________________
Nutrition:
How would you describe your nutritional diet?
❑ Very Unhealthy
❑ Somewhat Unhealthy ❑ Somewhat Healthy
❑ Very Healthy
Please outline your usual eating schedule and describe what you might eat during the work week:
Time
Description of Meal or Snack
How does what you eat on the weekends differ from the above?
_____________________________________________________________________________________
_____________________________________________________________________________________
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Please indicate how many servings/units you consume per day for the following:
Fruit
servings/day
Vegetables
servings/day
Proteins
servings/day
Desserts
servings/day
Sweetened beverages
servings/day
On a weekly basis, how often do you eat in restaurants, cafeterias, or away from home?
Breakfast ______times/week Lunch ______times/week Dinner ______times/week
Please describe the type of restaurants where you eat:
__________________________________________________________________________________
__________________________________________________________________________________
Are the people in your life supportive of you eating healthy?
❑ Yes ❑ No
For any health conditions you may have, which ones do you think may be related to your weight or diet?
_____________________________________________________________________________________
_____________________________________________________________________________________
Please indicate who prepares your meals:
❑ Self ❑ Spouse ❑ Roommate ❑ Other
Are there any special considerations in family meal planning?
❑ Yes ❑ No
If yes, please describe: _______________________________________________________________
__________________________________________________________________________________
Do you note anything that causes you to eat outside of regular meal times or actual hunger?
❑ Yes ❑ No
If yes, please describe: _______________________________________________________________
__________________________________________________________________________________
What is your usual body weight?
____________________________________________________
What is your desired body weight?
____________________________________________________
Have you experienced any changes in your weight?
❑ Yes ❑ No
If yes, please explain: ________________________________________________________________
__________________________________________________________________________________
What are your dietary goals? _____________________________________________________________
_____________________________________________________________________________________
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SYSTEMS
General:
What are your greatest concerns to your health (stress, sedentary lifestyle, diet, exercise, family history,
alcohol, drugs, etc.)?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Head:
Do you suffer from headaches?
❑ Yes ❑ No
If so, have they been formerly diagnosed (e.g., migraines, tension, cluster, etc.)?
❑ Yes ❑ No
Please explain: _____________________________________________________________________
Is your hearing compromised?
❑ Yes ❑ No
If yes, is there a past history of acoustic trauma, ear disease, or family history of a hearing deficit?
__________________________________________________________________________________
Has your vision changed in the past 1-2 years?
❑ Yes ❑ No
Have you ever noted temporary changes in your visual fields? (e.g., blind spots)
❑ Yes ❑ No
If so, which eye, how long, how frequent? _______________________________________________
Have you had an eye exam within the past two years?
❑ Yes ❑ No
Do you have a history of allergy symptoms?
❑ Yes ❑ No
Do you have a history of hoarseness or recurring irregularities of your voice?
❑ Yes ❑ No
Neck:
Do you have a history of pain or stiffness in your neck?
❑ Yes ❑ No
If so, are there factors that trigger the pain/stiffness? _____________________________________
Do you have a history of swollen glands in the neck?
❑ Yes ❑ No
If so, are they typically associated with a sore throat or signs of infection? _____________________
Have you ever experienced thyroid enlargement or tenderness in your neck?
❑ Yes ❑ No
Lymphatic System:
Do you have history of persistent swollen glands in your neck, underarms, groin or thighs? ❑ Yes ❑ No
If yes, please describe: _______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
10
Chest:
Have you experienced any of the following:
❑ Chest Pain ❑ Shortness of Breath ❑ Cough ❑ Chest Congestion
❑ Wheezing ❑ Reduced Tolerance to Exercise
Have you been diagnosed with any of the following:
❑ Asthma ❑ Emphysema ❑ COPD
Please provide details: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Heart:
Have you ever experienced chest pain caused by:
❑ Exertion ❑ Angina ❑ Heart Attack ❑ Congestive Heart Failure
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
Have you ever experienced any unusual sensations as a result of physical activity, such as:
❑ Tightness, ❑ Burning, ❑ Fullness ❑ Other
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
Do you have a history of:
❑ Skipped Heartbeats ❑ Excessively Rapid Heart Rhythm ❑ Irregular Heart Rhythm
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
Have you ever passed out?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Have you ever experienced swelling in your legs or ankles?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Have you experienced any pain in your leg muscles when walking that ceases when you halt activity?
❑ Yes ❑ No
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Abdomen:
Do you have a history of chronic or persistent:
❑ Abdominal Pain ❑ Indigestion ❑ Nausea ❑ Vomiting ❑ Diarrhea
❑ Constipation
❑ Endoscopy Procedures
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have a history of:
❑ Belching
❑ Stomach Acid ❑ Severe or Persistent ‘Heartburn’
If so, please list agitating factors: ______________________________________________________
Have you ever experienced jaundiced skin or noticed dark colored urine?
❑ Yes ❑ No
Have you noted any change in bowel habits, such as:
❑ Dark Color and Stature of Stool ❑ Straining at defecation
❑ Continued feeling of needing to clear your bowel after excreting stool
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you or anyone in your immediate family (grandparents, parents, siblings, children) had any of the
following conditions?
❑ Colon Cancer ❑ Colon Polyps (malignant or benign) ❑ Familial Adenomatous Polyposis
❑ Other Major Abdominal Disease
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Have you ever had a ❑ Colonoscopy ❑ Flexible Sigmoidoscopy ❑ Upper Endoscopy (EGD)?
If yes, when and what were the findings?
_____________________________________________________________________________________
_____________________________________________________________________________________
Genitourinary Tract (Female):
Do you have a history of repeated bladder or urinary tract infections?
❑ Yes ❑ No
Do you have a history of repeated vaginal infections?
❑ Yes ❑ No
If so, are they usually triggered by certain factors (e.g., taking antibiotics)
❑ Yes ❑ No
How many pregnancies have you had?
____________________
How many were full-term deliveries?
____________________
How many miscarriages?
____________________
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Did you breast-feed your children?
❑ Yes ❑ No
Were you ever informed that you had diabetic predispositions during pregnancy?
❑ Yes ❑ No
When was your last Pap smear? __________________________________________________________
Have you ever had an abnormal Pap smear?
❑ Yes ❑ No
If so, what actions were taken? ________________________________________________________
When was your last mammogram? ________________________________________________________
Have you ever had a mammogram with abnormal findings?
❑ Yes ❑ No
If so, when did this occur? ____________________________________________________________
How was this addressed? _____________________________________________________________
Have you experienced any indicators of menopause such as “hot flashes”, shifts in mood, personality
changes?
❑ Yes ❑ No
If so, are they currently diminishing, increasing, inactive? ___________________________________
Are you now, or in the future, planning to use hormonal replacement therapy to reduce effects of
menopausal changes?
❑ Yes ❑ No
Have you ever had bone density studies?
❑ Yes ❑ No
If yes, what were the results? _________________________________________________________
Extremities:
Do you experience chronic or recurring: ❑ Joint Pain ❑ Swelling ❑ Stiffness ❑ Redness
Have you experienced: ❑ Muscle Weakness ❑ Soreness ❑ Loss of Muscle Mass
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you experienced any changes in the fingernails or toenails?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Do you experience changes in the color or temperature of your hands or feet?
❑ Yes ❑ No
Skin:
Do you have any skin lesions that concern you?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had a skin lesion removed?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
13
_____________________________________________________________________________________
Neuropsychiatric:
Have you ever experienced significant anxiety or depression?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Sleep:
Do you currently have difficulty falling asleep or staying asleep?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Have you ever been told that you snore significantly?
❑ Yes ❑ No
When you wake in the morning, do you feel significantly fatigued?
❑ Yes ❑ No
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Has anyone told you that you stop breathing while asleep?
❑ Yes ❑ No
Other Pertinent Medical Information:
Are there other points that you feel should be included in your medical history?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
BREAKFAST
☐ Scrambled Eggs
Whole Wheat Toast
Fresh Fruit Cup
Bottled Water
Decaf Coffee or Decaf Tea
☐ Oatmeal with Assorted Toppings
(dried fruit, nuts, brown sugar)
Low Fat Vanilla Yogurt
Bottled Water
Decaf Coffee or Decaf Tea
☐ Egg White, Sautéed Spinach and Low Fat
Swiss Cheese in a Whole Wheat Tortilla
Fresh Fruit Cup
Bottled Water
Decaf Coffee or Decaf Tea
Calories
220
Carbohydrate 20 g
Fat
7 g
Fiber
3 g
Saturated Fat 1 g
Sugar
17 g
Cholesterol
250 mg Protein
11 g
Sodium
230 mg
Calories
470
Carbohydrate 59 g
Fat
20 g
Fiber
6 g
Saturated Fat 2 g
Sugar
62 g
Cholesterol
5 mg Protein
14 g
Sodium
90 mg
Calories
452
Carbohydrate 59 g
Fat
13 g
Fiber
9 g
Saturated Fat 6 g
Sugar
10 g
Cholesterol
20 mg Protein
23 g
Sodium
750 mg
LUNCH
☐ Grilled Chicken and Spinach Salad with
Strawberries and Mandarin Oranges
Fat Free Raspberry Vinaigrette Dressing
Whole Wheat Dinner Roll, Margarine
Fresh Fruit Cup
Bottled Water
☐ Fresh Ginger Herb Shrimp
with Broccoli and Brown Rice
Fresh Fruit Cup
Bottled Water
☐ Seasoned Turkey and Avocado in a Whole
Wheat Tortilla
Organic Lettuce and Tomato
Organic Carrot Sticks
Fresh Fruit Cup
Bottled Water
Calories
438
Carbohydrate 49 g
Fat
8 g
Fiber
9 g
Saturated Fat 1 g
Sugar
37 g
Cholesterol
30 mg Protein
37 g
Sodium
362 mg
Calories
310
Carbohydrate 49 g
Fat
2.5 g Fiber
5.5 g
Saturated Fat 0 g
Sugar
11.5 g
Cholesterol
120 mg Protein
20 g
Sodium
575 mg
Calories
503
Carbohydrate 55 g
Fat
14 g
Fiber
13.5 g
Saturated Fat 3.5 g Sugar
17.5 g
Cholesterol
30 mg Protein
13 g
Sodium
720 mg
Dietary Restrictions: _____________________________________________________________________