Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

CARDIOVASCULAR AND RESPIRATORY

Please check any conditions that apply to you.

High Blood Pressure

Heart Murmur

Valve Disorder

Abnormal Rhythm

Chest Pain

Heart Attack

Cardiac Surgery or Stents

Congestive Heart Failure

Peripheral Artery Disease

Thrombosis or DVT

Aneurysm

Asthma

COPD

Sleep Apnea

Shortness of Breath

Pulmonary Hypertension

Other Lung Disorder

Other Cardiac Disorder

GASTROINTESTINAL AND URINARY

Please check any conditions that apply to you.

Acid Reflux

Liver Disease

Bladder Disease

Kidney Disease

Hepatitis A, B, C

Other

METABOLIC/ENDOCRINE/AUTOIMMUNE

Please check any conditions that apply to you.

Hyper Thyroid

Hypo Thyroid

Diabetes (Type I)

Diabetes (Type II)

Lupus

Rheumatoid Arthritis

Hx of DKA

Other

NEUROLOGIC

Please check any conditions that apply to you.

Stroke/TIA

Multiple Sclerosis

Parkinson’s

Alzheimer’s

Seizures (list date of last seizure below)

HEMATOLOGY

Please check any conditions that apply to you.

Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)

MTHFR

G6PD Deficiency

MUSCULOSKELETAL

Please check any conditions that apply to you.

Back Pain

Degenerative Joint Disease

Carpal Tunnel Syndrome

Degenerative Disk Disease

Fibromyalgia

Other

PSYCHOLOGICAL

Please check any conditions that apply to you.

Depression

Anxiety or Panic Attacks

Suicidal Ideations

CANCER

Please check any conditions that apply to you.

Location of Cancer given below.

Chemotherapy

Radiation

PAIN

Please check any conditions that apply to you.

CRPS

Fibromyalgia

For Non-Menopausal Women

Date of Last Menstual Period

MM

DD

YYYY

Any chance that you are pregnant?

Yes

No

Are you currently breastfeeding?

Yes

No