• Medical History Questionaire


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  • Personal Health History

    In the last 10 years, have you been treated for or diagnosed with:
  • 1. High Blood Pressure, heart attack, chest pain, heart murmur, irregular heartbeat, stroke or any other disease of disorder of the heart or blood vessels?*
  • 2. Cancer, tumor, cyst or growth?*
  • 3. Asthma, bronchitis, emphysema, tuberculosis or any other disease or disorder of the lungs or respiratory system?*
  • 4. Seizure, paralysis, headache, multiple sclerosis or any other disease or disorder of the brain or nervous system?*
  • 5. Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder?*
  • 6. Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gallbladder, pancreas or digestive tract?*
  • 7. Diabetes, borderline diabetes, sugar in the urine, thyroid disorder or any other disease or disorder of the glandular system?*
  • 8. Kidney stones, nephritis, blood or protein in the urine, HIV, sexually transmitted disease, prostate disorder, breast disorder or any other disease or disorder of the urinary or reproductive system?*
  • 9. Any disease or disorder of the bones, joints or muscles?*
  • 10. Are you currently taking any medication?*
  • 11. Have your parents or siblings died from diabetes, cancer, stroke or heart disease?*

  • Activities & Health Habits within the last 5 years

  • 12. Have you used tobacco in any form (including gum/patch)*
  • 13. Engaged in any of the following activities: scuba/skin diving, pilot, organized motor vehicle racing, skydiving, hang gliding, mountain climbing or rodeo?*
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  • Should be Empty: