Medical History Form
Full Name
*
First Name
Last Name
Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Height
*
Weight
*
Target Weight
*
OCCUPATION
*
Which services are you interested in?
Libido Therapie
Muscle Building
Sport Therapie
Vitamins and Minerals
Weight Loss
Other
Please specify your interest "other"
Have you ever done medical weight loss program?
Yes
No
What Did you like about that program?
Why are you interested in weight loss program?
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment
Emergency Contact
*
First Name
Last Name
Relationship
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Do you have any medication allergies?
*
Yes
No
List Medication Allergies
Are you currently taking any medication?
*
Yes
No
List of Medication
Have you ever been diagnosed with any chronic illnesses? (e.g., diabetes, hypertension, asthma, etc.)
*
Yes
No
Any Known Deficiency Including Minerals and Electrolytes?
*
Yes
No
Thyroid, Diabetes or Other Endocrine Disorder Including Insulin Resistance?
*
Yes
No
Heart Disease Including Atherosclerosis, Angina, Heart Failure, Heart Attack?
*
Yes
No
Orthopedic or Muscle Disorder Including Fracture or Joint Disorders?
*
Yes
No
Do you currently have or ever had any of the following? If yes, please check below and explain in the provided field.
*
None of the Above
Blood Disorders
Asthma
Cancer
Cardiac disease
Diabetes
Emotional Disorders / Depression
Epilepsy
Hypertension
Liver disease
Gastrointestinal disorders (e.g.,GERD,IBS)
Respiratory conditions other than asthma (e.g., COPD)
Thyroid disorders
Kidney Disorders
Musculoskeletal Disorders
Infectious Diseases
Dermatological Conditions
Reproductive Health Conditions
Sleep Disorders
Psychiatric disorder
Immune Disorders
Gential-Urinary Disorder
Comemical Dependency
Hyperlipidemia
Lung Disorder
Neurological Disorders
Carpal Tunnel Syndrome
Arthritis
Upper Respiratory
Bursitis
Edema / Excess Fluid Retention
Rheumatism
Sports Injury(s)
Other
Please Provide Details Below:
Does an immediate family member currently have or ever had any of the following? If yes, please check below and explain in the provided field.
Cardiovascular Disease
Diabetes, Thyroid or Other Endocrine Disorder
Hypertension
Lipid Disorder
Prostate Cancer
Other Forms of Cancer
Other Illnesses
Explain Family Health History.
Do you use any kind of illegal drugs or have you ever used them?
Yes
No
What kind of drugs? How long have you used/been using them?
Do You Smoke?
*
Yes
No
Do You Drink Alcohol?
*
Yes
No
Do You Exercise?
*
Yes
No
Do You Take Supplements?
*
Yes
No
Please Explain Social History. Smoking And/Or Drinking Frequency. Exercise Type and Frequency. Type Of Supplments And Dosages.
Submit
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