Medical History Form

Medical History Form

We appreciate a few minutes of yours to share some vital information. Your data is processed in accordance with GDPR regulations: Please, contact bsacupuntura@gmail.com for any related subject. Healthy regards, www.kipuncture.com/bs
Full Name

First NameLast Name
What is your age?
What is your gender?
Contact Number
Email Address
example@example.com
Check the conditions that apply to you or any member of your immediate relatives:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Check the symptoms that you' re currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalTinnitusAmbliopyInsomniaFatigueMiasthenyOther
Which is the cause of your main complaint?

AccidentDrug usageExcercise reactionFood ingestionMedicationTherapy reactionVaccine reactionWork reactionI don't knowOther
Are you currently taking any medication?

YesNo
Please list them.
Do you have any medication allergies?

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
How often do you consume coffee?

More than trice per dayTrice per dayTwice per dayDailyWeeklyMonthlyOccasionallyNever
Are you interested in answering a more specific questionnaire related to your case?

Yes, pleaseNo, Thank youDepend on timeOutros
Should be Empty: