Diagnostic Testing Wellness Screening

Diagnostic Testing Wellness Screening
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender assigned at birth*
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 FatigueWeaknessFever/chillsNight SweatsDizzyFaintingWeight loss/gainSwollen glands
Head

HeadachesEye PainTrouble SeeingTrouble HearingNasal CongestionDental PainSore Throat
Breathing

CoughExcessive PhlegmBloody PhlegmShortness of breathWheezing
Heart & Circulation

Chest PainSwollen legs/anklesDifficulty walking up stairsLeg cramps after walkingPalpitationsTrouble breathing when laying flat
Digestive

Acid RefluxAbdominal PainPoor appetitieNausea/ VomitingConstipationDiarrheaBlood in vomit or stoolBlack or Tarry stoolsExcessive belching or passing gasRectal pain
Urinary

Pain/Burning with UrinationFrequent UrinationLeaking of urineBlood in UrineDecreased urine stream
Musculoskeletal

Muscle loss/ weaknessBack PainPainful muscles/tendonsPainful JointsSwollen JointsMorning StiffnessMuscle crampingRib painPain that comes & goes with movement w/out an apparent reason
Neurological

RadiatingPainTinglingNumbnessWeaknessBlackoutsTremorsSeizuresTrouble with Balance/ CoordinationTrouble with Memory/ ConcentrationTrouble processing numbers
Sex Health (Male)

Erection ProblemsLumps/Pain in TesticlesReduced Muscle MassLow Sex DriveHair Loss
Sex Health (Female)

Irregular bleedingLow Sex DriveLumps in BreastVaginal DrynessHair loss/Thinning hairMenstruation IrregularitiesHot flashes
Mental Health

Persistent SadnessWorryAnxietyGuiltFear/ParanoiaOver-energizedUnprovoked mood swingsPanic AttacksIrritabilityFlashbacksOver/under EatingWanting to harm myself or others
Other

Heat/Cold IntoleranceExcessive SweatingChanges in appetite or thirstSkin Changes/Rashes
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Diagnostic Testing Wellness Screening

Please select the following if they apply to you