Health History Form
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email Address
example@example.com
Age?
What is your gender?
Please Select
Male
Female
N/A
How long have you had Lyme disease?
# of years
On an average recent day what's your pain level?
None
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is None, 10 is Unbearable
When Lyme was at it's worst how much pain were you in?
None
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is None, 10 is Unbearable
Have you taken the Horowitz Lyme Questionnaire? If so do you remember your final number score?
Yes 33
Describe ALL your Lyme Disease symptoms and how long you've had them.
Left shouder pain 3 years; ringing in ears 2 years; etc.
List any other (non-Lyme) health challenges you're experiencing now.
Herpes, high blood pressure, diabetes, etc.
Are you currently taking any medication?
Yes
No
Please list them.
List your allergies
Do you smoke or use tobacco?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use recreational drugs (within the past month)?
Please Select
Yes
No
What kind of drugs? How long have you been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
How often do you drink soda?
Daily
Weekly
Monthly
Occasionally
Never
Briefly describe your diet please.
I'm vegetarian. I'm keto. I'm carnivore. I eat a lot of fast food. etc.
Back
Next
Please describe how Lyme has affected your life.
I am isolated and alone. I can't work. etc.
I acknowledge this is Alternative Medicine not Medical.
Yes
I acknowledge that no guarantee of a cure is made or implied.
Yes
Submit
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