First Name

    Middle Initial

    Last Name

    Email Address

    Phone (###-###-####)

    Personal History

    PLEASE CHECK THE BOX IF YOU HAVE BEEN DIAGNOSED WITH THE CONDITION.

    HIGH OR LOW BLOOD PRESURE
    VASCULAR DISEASE
    VLUNG DISEASE
    LUNG DISEASE
    ASTHMA OR COPD
    TB
    BRAIN TUMOR
    MIGRAINE OR HEADACHE
    LOSS OF HEARING
    VISUAL IMPAIRMENTS
    EPILEPSY/SEIZURES
    THYROID DIEASE
    HYPOTHYROID DIEASE
    HYPERTHYROID DIEASE
    GALLBLADDER DISEASE
    GASTRIC ULCER
    GASTRIC REFLUX
    PROSTATE ENLARGEMENT
    BLOOD IN STOOL OR URINE
    ARTHRITIS
    BACK PAIN
    NECK PAIN
    HEPATITIS A, B, C
    LIVER DISEASE
    HIV/AIDS
    KIDNEY DISEASE
    KIDNEY STONES
    DIABETES
    ANXIETY
    DEPRESSION
    MENTAL HEALTH ISSUES

    ADDICTION ISSUES SUCH AS :

    OPIOID DEPENCENCY
    ALCOHOL DEPENDENCY
    SUBSTANCE ABUSE
    ANY OTHER HEALTH ISSUES

    Family History

    I HAVE A FAMILY HISTORY OF:

    HEART DISEASE
    CANCER
    DIABETES
    EPILEPSY/SEIZURE
    LUNG DISEASE
    KIDNEY DISEASE
    DIABETES
    MENTAL DISORDER
    LIVER DISEASE
    ADDICTION
    OTHER CHRONIC CONDITIONS

    Social History

    Please 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 History

    PLEASE CHECK THE BOX IF YOU HAVE HAD THE SURGERY.

    APPENDECTOMY
    BACK SURGERY
    NECK SURGERY
    CABG
    REMOVAL OF GALLBLADDER
    FOOT SURGERY
    HYSTERECTOMY
    TONSILLECTOMY
    TUBAL LIGATION
    HEART SURGERY
    CARDIAC STENT PLACEMENT
    THYROID SURGERY
    OTHER