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Health History Form

Health History Form

Personal Info

name

Last name

Fullname / Nombre Completo

Gender *

Male

Female

Gender

DoB mm-dd-yyyy

age

Weight(lbs)

Height (ft)

Height (in)

Phone Number

E-mail

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Medical and Health Questions

Please name all the medical conditions you've been diagnosed with

Are you being treated by a physician now?

Are you being treated by a physician now? *

Yes

No

If your last answer was yes, please explain: / Si es asi, explique Por favor:

Please list all the medication you are currently taking

Please list all the supplements you are currently taking

Are you allergic to any medication? *

Yes

No

Are you allergic to any medication?

If yes, which one?

Have you experienced any substance abuse?

Recreational drug

Medications

Alcohol

Nicotine

Please mention the reason why you need this examination

When were you diagnosed with this medical condition?

Please elaborate on your current symptoms

Please select if you have experienced any of the following:

Heart Condition: (i. e. heart attack, heart failure, high blood pressure etc.)

If yes, specify:

Kidney Failure

If yes, what stage are you in?

Liver Disease

If yes, specify

Cancer

If yes, how long have you been in remission?

HIV/AIDS

Do you experience difficulty for any of the following?

Communicating

If yes, specify:

Breathing

If yes, specify:

Gynecological Medical Info*

Are you or could you be pregnant?

Yes

No

Are you nursing?

Yes

No

Are you taking birth control pills?

Are you taking birth controlling pills?

Yes

No

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Schedule Info

Preferred Location

When are you interested in scheduling?

How did you find us?

Explain

LEAD

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