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Medical History Form

What is your estimate of your general health?

Do you have or have you ever had:

Hospitalization for illness or injury
An allergic or bad reaction to any of the following:
Heart problems, or cardiac stent within the last six months
History of infective endocarditis
Artificial heart valve, repaired heart defect (PFO)
Pacemaker or implantable defibrillator
Orthopedic or soft tissue implant (e.g joint replacement, breast implant)
Heart murmur, rheumatic or scarlet fever
Heart murmur, rheumatic or scarlet fever
A stroke (taking blood thinners)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut (or INR > 3.5)
Pneumonia, emphysema, shortness of breath, sarcoidosis
Chronic ear infections, tuberculosis, measles, chicken pox
Breathing problems (e.g. asthma, stuffy nose, sinus congestion)
Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
Kidney Disease
Liver Disease or jaundice
Vertigo (e.g. ”the room is spinning”)
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
High cholesterol or taking statin drugs
Diabetes
Stomach or duodenal ulcer
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
Arthritis or gout
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
Glaucoma
Contact Lenses
Neck Injuries
Epilepsy, convulsions (seizures)
Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
STI/STD/HPV
Hepatitis
HIV/AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric treatment or antidepressant medication
Concentration problems or ADD/ADHD
Alcohol/recreational drug use

ARE YOU:

Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
Taking medication for weight management
Taking dietary supplements, vitamins, and/or probiotics
Often exhausted or fatigued
Experiencing frequent headaches or chronic pain
A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)
Considered a touchy/sensitive person
Often unhappy or depressed
Taking birth control pills
Currently pregnant
Diagnosed with a prostate disorder

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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