First NameMiddle InitialLast NameEmail AddressPhone (###-###-####)Personal HistoryPLEASE CHECK THE BOX IF YOU HAVE BEEN DIAGNOSED WITH THE CONDITION.HIGH OR LOW BLOOD PRESUREVASCULAR DISEASEVLUNG DISEASELUNG DISEASEASTHMA OR COPDTBBRAIN TUMORMIGRAINE OR HEADACHELOSS OF HEARINGVISUAL IMPAIRMENTSEPILEPSY/SEIZURESTHYROID DIEASEHYPOTHYROID DIEASEHYPERTHYROID DIEASEGALLBLADDER DISEASEGASTRIC ULCERGASTRIC REFLUXPROSTATE ENLARGEMENTBLOOD IN STOOL OR URINEARTHRITISBACK PAINNECK PAINHEPATITIS A, B, CLIVER DISEASEHIV/AIDSKIDNEY DISEASEKIDNEY STONESDIABETESANXIETYDEPRESSIONMENTAL HEALTH ISSUESADDICTION ISSUES SUCH AS :OPIOID DEPENCENCYALCOHOL DEPENDENCYSUBSTANCE ABUSEANY OTHER HEALTH ISSUESFamily HistoryI HAVE A FAMILY HISTORY OF:HEART DISEASECANCERDIABETESEPILEPSY/SEIZURELUNG DISEASEKIDNEY DISEASEDIABETESMENTAL DISORDERLIVER DISEASEADDICTIONOTHER CHRONIC CONDITIONSSocial HistoryPlease select the box if the answer is 'Yes' to the question.Do you live alone?Do you have a stable housing situation?Do you have children?Do you have child custody issues?Do you drink alcohol?Do you drink caffeinated beverages?Do you take non-prescribed drugs?Are you employed?Are you disabled?Do you smoke cigarettes?Do you vape?Do you have unresolved legal issues?Are you on probation?Do you have adequate food?Do you have transportation?Are you under more stress than normal?Surgical HistoryPLEASE CHECK THE BOX IF YOU HAVE HAD THE SURGERY.APPENDECTOMYBACK SURGERYNECK SURGERYCABGREMOVAL OF GALLBLADDERFOOT SURGERYHYSTERECTOMYTONSILLECTOMYTUBAL LIGATIONHEART SURGERYCARDIAC STENT PLACEMENTTHYROID SURGERYOTHERBy hitting "Submit," you are agreeing to have your form signed and submitted electronically.
