Health

First Name *

Last Name *

Patient Sex

Address

City

State

Zip

Email *

Home Phone Number

Cell Phone Number

Marital status

Occupation

Birthdate

Primary Doctor

Date of last physical exam

Doctor Address

Doctor City

Doctor State

Doctor Zip

Doctor Phone Number

Who recomended you

Medical history and dates of diagnosis

Medical history and dates of diagnosis:

Date of Diagnosis

Diagnosis

Date of Diagnosis

Diagnosis

Date of Diagnosis

Diagnosis

Surgeries

Surgeries

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

Other Hospitalizations

Other Hospitalizations

Year

Reason

Hospital

Year

Reason

Hospital

Year

Reason

Hospital

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug

Strength

Frequency Taken

Name the Drug

Strength

Frequency Taken

Name the Drug

Strength

Frequency Taken

Allergies to medications, foods, or supplements

Allergies to medications, foods, or supplements

Name of Product

Reaction you Had

Name of Product

Reaction you Had

Name of Product

Reaction you Had

Name of Product

Reaction you Had

Name of Product

Reaction you Had

Name of Product

Reaction you Had

Health Habits and Screening

Health Habits and Screening

Daily Cups of Coffe

Daily Cups of Tea

Daily Cans of Cola

Do you drink alcohol?

Do you use tobacco?

Do you currently use recreational drugs?

Family Health History

Family Health History

Father

Father

Age

Significant Health Problems

Mother

Mother

Age

Significant Health Problems

Do you have a history of substance abuse?

Is stress a major problem for you?

Do you feel depressed?

Have you been traeted for depression, anxiety, panic attacks, or bi-polar disorder?

Do you panic when stressed?

Do you have a history of an eating disorder?

Are you or have you been under pychiatric care?

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain

Skin

Chest/Heart

Recent changes in:

Head/Neck

Back

Weight

Ears

Intestinal

Energy level

Nose

Bladder

Ability to sleep

Throat

Bowel

Other pain/discomfort:

Lungs

Circulation

Name of Product

Submit

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