Fuel for Life

You are here:
Home
Medical Form

Contact Information
Name*
First Last
Email*
Questionnaire
Do you have any allergies to medications, plants, animals, or foods?*
Please list any allergies you have, one per line.
Do you use any over-the-counter medication regularly?*
Please list any over-the-count medication you use regularly, one per line.
Do you use any vitamins, minerals, herbs, or other supplements daily?*
Please list any vitamins, minerals, herbs and/or other supplements you use regularly one per line.
Do you have asthma or exercise-induced asthma?*
Have you ever had a seizure?
Do you have epilepsy?
Do you have diabetes or high resting blood sugar?*
Are you or have you been anemic?*
Have you been diagnosed with an eating disorder?*
Please explain.
Are you being treated for high blood pressure?*
Please explain.
Do you have or have you ever had heart disease?*
Please explain.
To your knowledge, do you have any family history of heart disease, diabetes, stroke, or other chronic disease (in parents)?*
Please explain.
Do you have or have you ever had lung disease?*
Please explain.
Do you have or have you ever had kidney disease?
Please explain.
Do you have or have you ever had liver disease?
Please explain.
Do you have or have you ever had stomach disease (ulcers, bleeding, etc.)?*
Please explain.
Do you have or have you ever had frequent headaches?*
Please explain.
Have you ever had a head injury?*
Please explain.
Have you ever had a broken bone or fracture?
Please explain.
Have you ever had a surgery?*
Please list the surgeries and dates one per line.
When was your last blood test? What were the findings?
MM slash DD slash YYYY
Describe your sleep patterns.*
Are you taking birth control?*
Please list which type and for how long.
Please choose:*
How often do you have periods and for what duration?
Other Information
The above questions have been answered correctly and truthfully to the best of my knowledge.*
- Yes

Save and Continue Later

Medical Form

Contact Information

Questionnaire