Diagnostic Testing Wellness Screening
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender assigned at birth
*
Please Select
Male
Female
Height
Weight
The Reason you are seeking Health Consult. Any Health concerns?
Are you looking for any Specific testing/treatments?
Past Medical/Surgical History
What medications are you currently taking?
Are you currently taking any supplements?
Allergies to Medication/Foods?
Do you follow any specific diet? ie. vegan, vegetarian, low carb ect.
Please select the following if they apply to you
General
Persistent Fatigue
Weakness
Fever/chills
Night Sweats
Dizzy
Fainting
Weight loss/gain
Swollen glands
Head
Headaches
Eye Pain
Trouble Seeing
Trouble Hearing
Nasal Congestion
Dental Pain
Sore Throat
Breathing
Cough
Excessive Phlegm
Bloody Phlegm
Shortness of breath
Wheezing
Heart & Circulation
Chest Pain
Swollen legs/ankles
Difficulty walking up stairs
Leg cramps after walking
Palpitations
Trouble breathing when laying flat
Digestive
Acid Reflux
Abdominal Pain
Poor appetitie
Nausea/ Vomiting
Constipation
Diarrhea
Blood in vomit or stool
Black or Tarry stools
Excessive belching or passing gas
Rectal pain
Urinary
Pain/Burning with Urination
Frequent Urination
Leaking of urine
Blood in Urine
Decreased urine stream
Musculoskeletal
Muscle loss/ weakness
Back Pain
Painful muscles/tendons
Painful Joints
Swollen Joints
Morning Stiffness
Muscle cramping
Rib pain
Pain that comes & goes with movement w/out an apparent reason
Neurological
RadiatingPain
Tingling
Numbness
Weakness
Blackouts
Tremors
Seizures
Trouble with Balance/ Coordination
Trouble with Memory/ Concentration
Trouble processing numbers
Sex Health (Male)
Erection Problems
Lumps/Pain in Testicles
Reduced Muscle Mass
Low Sex Drive
Hair Loss
Sex Health (Female)
Irregular bleeding
Low Sex Drive
Lumps in Breast
Vaginal Dryness
Hair loss/Thinning hair
Menstruation Irregularities
Hot flashes
Mental Health
Persistent Sadness
Worry
Anxiety
Guilt
Fear/Paranoia
Over-energized
Unprovoked mood swings
Panic Attacks
Irritability
Flashbacks
Over/under Eating
Wanting to harm myself or others
Other
Heat/Cold Intolerance
Excessive Sweating
Changes in appetite or thirst
Skin Changes/Rashes
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