Personal History Form






    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