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Medical & Health History

Medical & Health History Screen

Name
First Last
Today's Date*
MM slash DD slash YYYY
Your Date of Birth*
MM slash DD slash YYYY
Your Age Please*
Your Gender*
Your Primary Phone Number*
Your Primary Residence Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Email (necessary to send you a copy)*
Enter Email Confirm Email
Do you have any diagnosed or treated health conditions?*
Please select all the health risk factors that pertain to you.*
- Clinical Obesity
- Heart Attack
- Autoimmune disease
- Heart Murmur
- Hypoglycemia
- High Cholesterol
- High Blood Pressure
- Balance or Vision
- Abnormal ECG
- Renal Failure
- Emphysema
- Respiratory disease
- Osteoporosis
- Thyroid disorder
- Kidney / Liver disirder
- Diabetes
- Cancer
- Asthma
- Hernia
- Arthritis
- Anemia
- Eating / Food Disorder
- Spinal disorder
- Blood disease / Bone Marrow failure
When was your last complete exam?*
MM slash DD slash YYYY
Have you had any medical treatment, hospitalization or surgeries in the past 5 years?*
Please list and describe those treatments or surgeries.*
Do you have any joint pain or range of motion limitations?*
Please list and describe all movement pain or limiations*
Are you currently taking any prescribed medications?*
Please list ALL medications that you are currently taking*
Medication Condition Dosage (amt & frequency) For how long?

Please add a new row for each medication you are taking.
Please provide any additional medical or health explanations here that you otherwise could not add prior.
Email
This field is for validation purposes and should be left unchanged.

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Medication	Condition	Dosage (amt & frequency)	For how long?