Medical History.

Thank you for taking the time to complete your medical history online. If you need assistance, please feel free to contact us at your convenience.

Patient Name *
Patient Name
Date of most recent physical examination
Date of most recent physical examination
What is your estimate of your general health? *
DO YOU HAVE OR HAVE YOU EVER HAD...?
Hospitalization for illness or injury? *
An allergic reaction to...? (Please select all that apply) *
Heart problems, or cardiac stent within the last six (6) months? *
History of infective endocarditis? *
Artificial heart valve, repaired heart defect (PFO)? *
Pacemaker or implantable defibrillator? *
Artificial prosthesis (heart valve or joints)? *
Rheumatic or scarlet fever? *
High or low blood pressure? *
A stroke (taking blood thinners)? *
Anemia or other blood disorder? *
Prolonged bleeding due to a slight cut (INR>3.5) *
Emphysema, sarcoidosis? *
Tuberculosis? *
Asthma? *
Breathing or sleep problems (i.e.: snoring, sinus) *
Kidney disease? *
Liver disease? *
Jaundice? *
Thyroid, parathyroid disease, or calcium deficiency? *
Hormone deficiency? *
High cholesterol or taking statin drugs? *
Diabetes? *
Stomach or duodenal ulcer? *
Digestive disorders (i.e.: gastric reflux)? *
Osteoporosis/osteopenia (i.e.: taking bisphosphonates)? *
Arthritis? *
Glaucoma? *
Contact lenses? *
Head or neck injuries? *
Total joint replacement (i.e.: hip, knee, etc.)? *
If yes, when was your total joint replacement surgery?
If yes, when was your total joint replacement surgery?
Epilepsy, convulsions (seizures)? *
Neurologic problems (attention deficit disorder)? *
Viral infections and cold sores? *
Any lumps or swelling in the mouth? *
Hives, skin rash, hay fever? *
Venereal disease? *
Hepatitis? *
HIV/AIDS? *
Tumor or abnormal growth? *
Radiation therapy? *
Chemotherapy? *
Emotional problems? *
Psychiatric treatment? *
Antidepressant medication(s)? *
Alcohol and/or drug dependency? *
ARE YOU...?
Presently being treated for any other illness? *
Aware of a change in your general health? *
Taking medication for weight management (i.e.: fen-phen)? *
Taking dietary supplements? *
Often exhausted or fatigued? *
Subject to frequent headaches? *
A smoker or smoked previously? *
Considered a touchy person? *
Often unhappy or depressed? *
FEMALE: Taking birth control pills?
FEMALE: Pregnant?
MALE: Prostate disorders?
List all medications, supplements, and/or vitamins taken within the last two (2) years.
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING. AFTER YOU HAVE CAREFULLY FILLED OUT THIS ONLINE FORM. PLEASE SUBMIT IT SECURELY BY PRESSING "SUBMIT" BELOW.