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Medical Form
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Medical Form
Contact Information
Name
*
First
Last
Email
*
Questionnaire
Do you have any allergies to medications, plants, animals, or foods?
*
-
Yes
No
Do you use any over-the-counter medication regularly?
*
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Yes
No
Do you use any vitamins, minerals, herbs, or other supplements daily?
*
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Yes
No
Do you have asthma or exercise-induced asthma?
*
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Yes
No
Have you ever had a seizure?
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Yes
No
Do you have epilepsy?
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Yes
No
Do you have diabetes or high resting blood sugar?
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Yes
No
Are you or have you been anemic?
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Yes
No
Have you been diagnosed with an eating disorder?
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Yes
No
Are you being treated for high blood pressure?
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Yes
No
Do you have or have you ever had heart disease?
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Yes
No
To your knowledge, do you have any family history of heart disease, diabetes, stroke, or other chronic disease (in parents)?
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Yes
No
Do you have or have you ever had lung disease?
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Yes
No
Do you have or have you ever had kidney disease?
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Yes
No
Do you have or have you ever had liver disease?
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Yes
No
Do you have or have you ever had stomach disease (ulcers, bleeding, etc.)?
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Yes
No
Do you have or have you ever had frequent headaches?
*
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Yes
No
Have you ever had a head injury?
*
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Yes
No
Have you ever had a broken bone or fracture?
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Yes
No
Have you ever had a surgery?
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Yes
No
When was your last blood test? What were the findings?
Describe your sleep patterns.
*
Are you taking birth control?
*
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Yes
No
Please choose:
*
-
Pre-menopausal
Peri-menopausal
Menopausal
Post-menopausal
None of the above
Other Information
The above questions have been answered correctly and truthfully to the best of my knowledge.
*
Yes
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