Medical History Form

1
Full Name* This field is required.
First Name
Last Name
2
Birth Date* This field is required.
Month
Day
Year
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email Address* This field is required.
example@example.com
5
Contact Number* This field is required.
6
What is your age?* This field is required.
7
What is your gender?
Please Select
Please Select
Male
Female
N/A
8
Weight* This field is required.
9
Height* This field is required.
10
Do you have any medication allergies?* This field is required.
Yes
No
Not Sure
11
Please list them.
12
What reaction do you have?ex. hives
13
Have you taken GSH before?* This field is required.
Yes
No
14
If so in what form:
Injection
IV infusion
Nasal Spray
15
Are you taking GSH now?* This field is required.
Yes
No
16
If so in what form:
Injection
IV infusion
Nasal Spray
17
Have you ever given yourself an injection?
Yes
No
18
Have you ever had problems using injections of any kind?
Yes
No
19
If so please describe:
20
List last set of vitals:if applicable
Blood Pressure and Pulse
21
What are your Top 3 Health Goals?* This field is required.
Decrease Inflammation
Alzheimer's
Improve Pain
Improve Energy
Detoxify Liver
Boost Immunity
COVID Brain
ADHD
Improve Mood, Depression and Anxiety
Improve Arthritis or Fibromyoalgia
Diabetes
Hypertension
Improve Skin Condition
Weight Loss
Restore Antioxidant-Free Radical Imbalance
Male Infertility
Muscle Building
Improve Sleep Disturbance
22
Check any of the conditions that you're currently experiencing:* This field is required.
Pain
Heart Disease
High Blood Pressure
Depression
Gastrointestinal
Weight Resistance
Weight Issues
Anxiety
Chronic Fatigue Syndrome
Migraines
Asthma or COPD
Atherosclerosis
Inflammation
Walking Imbalance
Infections
Vitamin Deficiency
Malabsorption
Acne
Psoriasis
Allergies
Cancer
Blood Clots
Liver or Kidney Problems
High Cholesterol
Dialysis
Insomnia
Other
23
Do you have any Medical Diagnosis?
Yes
No
24
Top 5 Medical Diagnosis
25
Have you had a major surgery?
Yes
No
26
List most recent surgeries
27
Are you currently taking any medication?* This field is required.
Yes
No
28
List Current Medications
Huge
Large
Normal
Small
Ok
Ok
29
Please upload your most recent labs if applicable:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
Is there anything else you would like your prescriber to know about your condition or health?
31
Are you currently using any of the following:* This field is required.
Tobacco
Alcohol
Illicit drugs
Herbs: prescription and non prescription
None
32
Are you currently pregnant or breastfeeding?* This field is required.We do not recommend taking vitamin injections while pregnant or breastfeeding
Yes
No
33
Terms and Conditions* This field is required.
34
Consent to Treatment* This field is required.
35
Injection Education* This field is required.
36
HIPAA* This field is required.
37
How did you hear about us?
Google Search
Social Media
Friend
Advertisement
Other
Should be Empty: