Medical History – Prescriptions Are you currently taking and/or prescribed any medications?* What medication(s) are you currently taking/prescribed?*
Please provide the name of the medication, dosage, reason for medication, and the name of prescribing physician.
Have you taken/been prescribed any medication(s) in the past 2 years that you no longer take?* What past medications were prescribed?*
Please provide the name of the medication, dosage, reason for medication, and the name of prescribing physician.
Are you currently taking any vitamins or supplements?* What vitamin(s)/supplement(s) do you take?*
Blood Pressure and Cholesterol Related Disease or Disorders* (High cholesterol, high blood pressure)
Please provide details on BP and Cholesterol related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Ear, Nose, or Throat Related Disease or Disorders* (Esophagitis, difficulty swallowing, hearing loss, tinnitus, Meniere’s, severe sinus infections, other related conditions)
Please provide details on ENT related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Heart and Cardiovascular Related Disease or Disorders* (Heart attack, coronary artery disease, chest pain, heart murmur, palpitations, arrhythmia, irregular heartbeat, stent/other surgery, other disorder of the heart or blood vessels)
Please provide details on Heart/Cardiovascular System related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Cancer and Tumor Related Disease or Disorders* (Any type of cancer, benign/malignant tumors, basal cell carcinoma, melanoma, other related cancer disorders)
Please provide details on Cancer/Tumor related conditions:*
Name of condition(s), stage/type, date of diagnosis, type of treatment, name and location of physician, and date of remission if applicable.
Cyst, Polyp, Growth, Skin Related Disease or Disorders* (Psoriasis, eczema, colon polyps, bakers cyst, ovarian cyst, other related disorders)
Please provide details on Cyst/Polyp/Growth/Skin related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Lungs and Respiratory Related Disease or Disorders* (Asthma, sleep apnea, COPD, tuberculosis, sarcoidosis, pneumonia, emphysema, bronchitis, other related conditions)
Please provide details on Lung/Respiratory related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Brain, Spinal Cord, and Nervous System Related Disease or Disorders* (Chronic headaches, migraines, MS, seizures, stroke, TIA, loss of consciousness, tremors, fainting, other related disorders)
Please provide details on Brain/Spinal Cord/Nervous System related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Emotional and Psychological Related Disease or Disorders* (Chronic fatigue, stress, depression, anxiety, PTSD, ADD/ADHD, bipolar disorder, eating disorders, other related disorders)
Please provide details on Emotional/Psychological related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Liver, Gallbladder, and Pancreas Related Disease or Disorders* (Gallstones, hepatitis, fatty liver disease, cirrhosis, pancreatitis, other related disorders)
Please provide details on Liver/Gallbladder/Pancreas related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Stomach, Colon, and Digestive Related Disease or Disorders* (Crohn’s, colitis, IBS, hernia, GERD, diverticulitis, other related disorders)
Please provide details on Stomach/Colon/Digestive related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Diabetes, Thyroid, and Glandular Related Disease or Disorders* (Type 1 or 2 diabetes, high blood sugar, Cushing’s Syndrome, pituitary gland disorder, hypothyroid, other related disorders)
Please provide details on Diabetes/Thyroid/Glandular related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Urinary and Kidney Related Disease or Disorders* Protein/blood/sugar in urine, polycystic kidney disease, kidney stones, chronic kidney disease, other related disorders)
Please provide details on Urinary/Kidney related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Prostate and Reproductive Related Disease or Disorders* (Prostatitis, benign prostatic hyperplasia, hormone deficiency, sexually transmitted disease, other related disorders.)
Please provide details on Prostate/Reproductive related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Uterus, Cervix, Ovaries, Breasts Related Disease or Disorders* (Endometriosis, polycystic ovary syndrome, uterine fibroids, interstitial cystitis, STD, other reproductive related disorders)
Please provide details on Reproductive related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Are you currently pregnant?* Any past or present complications of pregnancy or pregnancy related disorders?* (Gestational diabetes, preeclampsia, ectopic pregnancy, other related disorders.)
Please provide details on Pregnancy related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Bones, Joint, and Muscle Related Disease or Disorders* (Arthritis, sciatica, gout, disc problems, carpel tunnel, fibromyalgia, osteoporosis, recurring pain, fracture, other related disorders.)
Please provide details on Bones/Joints/Muscle related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
Blood and Immune System Related Disease or Disorders* (Anemia, Celiac Disease, Guillain-Barre Syndrome, Leukemia, Lupus, Lymphoma, Sjorgen’s Syndrome, Sickle Cell Disease, other related disorders.)
Please provide details on Blood/Immune System related conditions:*
Name of condition(s), date of diagnosis, stability of condition, name and location of physician, meds/treatments, and date of recovery if applicable.
HIV or AIDS* Please provide details on HIV/AIDS history:*
HIV or AIDS, date of diagnosis, stability of condition, name and location of physician, meds/treatments.
Other than previously mentioned, in the past 5 years have you had any diagnostic tests performs? (check all that apply)* Please provide details for the diagnostic testing performed:*
Type of test, date of test, reason for test, results, name and location of physician, and date of any follow up testing.
Other than previously mentioned, do you have a referral to a physician that has not yet been completed?* Have any of your current physicians referred you to another physician?
Please provide details for the physician referral:*
Name of the referring physician, name of physician you were referred to, date of referral, reason for referral and date of appointment (if scheduled).
Other than previously mentioned, have you visited any other physicians or had any surgeries/procedures in the last 5 years?* Have you visited any physician, hospital, clinic, had surgery, biopsy, or test that has not been previously disclosed?
Please provide details on other visit/procedure:*
Please provide the name and location of the facility/physician, reason for the visit/type of procedure, date of visit(s).