Medical History Intake
Please select which state you are interested in?(Required)
*
Please Select
Arizona
Colorado
Indiana
Massachusetts
Email(Required)
*
example@example.com
Best Contact Number
*
Please enter a valid phone number.
Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender(Required)
*
Please Select
Male
Female
Prefer Not to Answer
Marital Status
Please Select
Please Select one
Single
Married
Divorced
Widowed
Height
Weight
Current Employment Status
Please Select
Employed
Not Employed
Retired
Student
Highest Level of Education
Please Select
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Other
Prefer Not to Answer
Race
*
Please Select
American Indian or Alaskan Native
Asian
Black or African American
White
Native Hawaiian or Pacific Islander
More than one race; specify:
More than one race; specify:
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Emergency Contact Relationship
Primary Care / Family Physician Name
Date of last visit?
Have you ever participated in a research study before?
*
Yes
No
If Yes, Date and Indidication?
Are you currently taking any medications or supplements?
*
Yes
No
If Yes, please list all active (used within the past 30 days) medications and supplements, including dosage and how many time taken per day.
Immunological Conditions
*
AIDS/HIV
Allergies
Autoimmune Disease (RA, Lupus, etc.)
Rheumatic Fever
Other
None
Do you have AIDS/HIV?
*
Yes
No
Are you taking any medications for AIDs/HIV?
*
Yes
No
Do you or have you had Rheumatic Fever?
*
Yes – Condition is ongoing
No – Condition has resolved
No
Are you taking any medications for Rheumatic Fever?
*
Yes
No
Do you have Allergies?
*
Yes – Condition is ongoing
No – Condition has resolved
No
Are you taking any medications for Allergies?
*
Yes
No
Do you have an Autoimmune Condition?
*
Yes
No
Are you taking any medications for Autoimmune Disease?
*
Yes
No
Please describe "Other" Immunological Condition:
*
Place "N/A" if not applicable
Is "Other" Immunological Condition Ongoing ?
*
Yes
No
Are you taking any medications for a Immunological Condition?
*
Yes
No
Cardiovascular Conditions
*
Angina (Chest Pain)
Bleeding Problems
Blood Clots
Bypass Surgery
Chronic Heart Failure (CHF)
Fainting and/or blackouts
Heart Attack
High Blood Pressure
High Cholesterol
Irregular/rapid heartbeat
Low Blood Pressure
Pacemaker
Peripheral Artery Disease (PAD)
Shortness of Breath
Stent Placement
Stroke or TIA
Other
None
Do you have Angina?
*
Yes
No
Are you taking any medications for Angina?
*
Yes
No
Do you have Chronic Heart Failure (CHF)?
*
Yes
No
Are you taking any medications related to CHF?
*
Yes
No
Do you have High Blood Pressure?
*
Yes
No
Are you taking any medications for High Blood Pressure?
*
Yes
No
Do you have Shortness of Breath?
*
Yes
No
Are you taking any medications for Shortness of Breath?
*
Yes
No
Do you have Low Blood Pressure?
*
Yes
No
Are you taking any medications for Low Blood Pressure?
*
Yes
No
Do you have High Cholesterol?
*
Yes
No
Are you taking any medications for High Cholesterol?
*
Yes
No
Have you had a Transient Ischemic Attack (TIA)?
*
Yes
No
Are you taking any medications for TIA?
*
Yes
No
Do you have a history of Blood Clots?
*
Yes
No
Are you taking any medications for Blood Clots?
*
Yes
No
Do you have a history of Bleeding Problems?
*
Yes
No
Are you taking any medications for Bleeding Problems?
*
Yes
No
Have you had a Heart Attack?
*
Yes
No
Are you taking any medications for Heart Attack?
*
Yes
No
Are you taking any medications for Stent Placement?
*
Yes
No
Are you taking any medications for Bypass Surgery?
*
Yes
No
Is PAD Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for PAD?
*
Yes
No
Are you taking any medications related to Pacemaker?
*
Yes
No
Do you have a Irregular Heartbeat Medical Condition?
*
Yes
No
Are you taking any medications for Irregular Heartbeat?
*
Yes
No
Is Fainting Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Fainting?
*
Yes
No
Please describe Other:
*
Write "N/A" if not applicable
Is "Other" Cardiovascular Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Cardiovascular condition?
*
Yes
No
Dermatological Conditions
*
Skin Cancer Type/Location:
Actinic Keratosis (Precancerous Skin Growth)
Atopic Dermatitis (Eczema)
Psoriasis/Plaque Psoriasis
Scarring Acne
Hidradenitis Suppurativa (HS)
Rosacea
Shingles
Diabetic Foot Ulcer (R/L/BL)
Pressure Ulcer
Rash
Other
None
Please describe skin cancer type and location:
*
Write "N/A" if not applicable
Is Skin Cancer Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Skin Cancer?
*
Yes
No
Is AK Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for AK?
*
Yes
No
Is Eczema Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Eczema?
*
Yes
No
Is Psoriasis Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Psoriasis?
*
Yes
No
Do you have Scarring Acne?
*
Yes
No
Are you taking any medications for Scarring Acne?
*
Yes
No
Is HS Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for HS?
*
Yes
No
Is Rosacea Ongoing?
*
Yes
No
Are you taking any medications for Rosacea?
*
Yes
No
Is Shingles Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Shingles?
*
Yes
No
Do you currently have a Diabetic Foot Ulcer?
*
Yes
No
Are you taking any medications for Diabetic Foot Ulcer?
*
Yes - Please answer question below.
No
What was the location of your Diabetic Foot Ulcer:
Right foot
Left foot
Both feet
Right Ankle
Left Ankle
Both Ankles
Do you have a current Pressure Ulcer?
*
Yes
No
Are you taking any medications for Pressure Ulcer?
*
Yes
No
Do you have a Rash?
*
Yes
No
Are you taking any medications for Rash?
*
Yes
No
Please describe Other Dermatological Conditions:
*
Write "N/A" if not applicable
Is "Other" Dermatological Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Dermatological Conditions?
*
Yes
No
Ears, Nose and Throat Conditions
*
Allergies/Sinusitis
Hearing Loss
Ear Pain or Itch
Dizziness
Nasal Congestion
Hoarseness
Sinus Pressure or Pain
Snoring or Apnea
Throat Pain
Other
None
Do you have Allergies/Sinusitis?
*
Yes
No
Are you taking any medications for Allergies/Sinusitis?
*
Yes
No
Do you currently have hearing loss?
*
Yes
No
Are you taking any medications for Hearing Loss?
*
Yes
No
Is Ear Pain Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Ear Pain?
*
Yes
No
Is Dizziness Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Dizziness?
*
Yes
No
Is Nasal Congestion Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Nasal Congestion?
*
Yes
No
Is Hoarseness Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Hoarseness?
*
Yes
No
Is Sinus Pressure Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Sinus Pressure?
*
Yes
No
Is Snoring/Apnea Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Snoring/Apnea?
*
Yes
No
Is Throat Pain Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Throat Pain?
*
Yes
No
Please describe "Other" ENT Conditions:
*
Write "N/A" if not applicable
Is "Other" ENT Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" ENT Condition?
*
Yes
No
Genitourinary Conditions
*
Urinary Frequency
Burning with Urination
Blood in Urine
Problems Urinating
Problems with Sex (ED/Menopause)
Sexually Transmitted Infection (STI)
Benign Prostatic Hyperplasia (BPH)
Kidney Stones
Kidney Problems
Other
None
Do you have Urinary Frequency?
*
Yes
No
Are you taking any medications for Urinary Frequency?
*
Yes
No
Do you have burning with urination?
*
Yes
No
Are you taking any medications for Burning with Urination?
*
Yes
No
Do you have Blood in Urine?
*
Yes
No
Are you taking any medications for Blood in Urine?
*
Yes
No
Do you have problems urinating?
*
Yes
No
Are you taking any medications for Problems Urinating?
*
Yes
No
Do you have problems with Sex?
*
Yes
No
Are you taking any medications for Problems with Sex?
*
Yes
No
Do you have a Sexually Transmitted Infection?
*
Yes
No
Are you taking any medications for Sexually Transmitted Infection?
*
Yes
No
Name of sexually transmitted infection, if known:
*
Write "N/A" if not applicable
Do you have an Enlarged Prostate (BPH)?
*
Yes
No
Are you taking any medications for an Enlarged Prostate (BPH)?
*
Yes
No
Are Kidney Stones Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Kidney Stones?
*
Yes
No
Do you have Kidney Problems?
*
Yes
No
Are you taking any medications for Kidney Problems?
*
Yes
No
Please describe "Other" Genitourinary Condition:
*
Write "N/A" if not applicable
Is "Other" Genitourinary Conditions Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Genitourinary Conditions?
*
Yes
No
Gastrointestinal Conditions
*
Nausea
GERD (Reflux/Heartburn)
Vomiting (Single Episode/Constant)
Constipation (Intermittent/Chronic)
Abdominal Pain (Intermittent)
Diarrhea (Intermittent)
Blood in Stool
Lactose intolerance
Diverticulitis
Crohn’s Disease/Ulcerative Colitis
Gallstones
Hernia
Gastric Bypass Surgery
Gastric/Peptic Ulcer(s)
Irritable Bowel Syndrome (IBS)
Celiac Disease
Hepatitis (Infection type if known)
Other
None
Do you have Nausea?
*
Yes
No
Are you taking any medications for Nausea?
*
Yes
No
Do you have GERD?
*
Yes
No
Are you taking any medications for GERD?
*
Yes
No
Vomiting (Single Episode/Constant)
*
Single Episode
Constant
Not Applicable
Is Vomiting an Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Vomiting?
*
Yes
No
Do you have Constipation (Intermittent/Chronic)
*
Yes - please answer the question(s) below
No
Not Applicable
Constipation (Intermittent/Chronic)
Intermittent
Chronic
Are you taking any medications for Constipation?
*
Yes
No
Is Abdominal Pain Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Abdominal Pain?
*
Yes
No
Is Diarrhea Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Diarrhea?
*
Yes
No
Have you or do you currently have blood in your stool?
*
Current
Past
Not Applicable
Are you taking any medications for Blood in Stool?
*
Yes
No
Are you Lactose Intolerant?
*
Yes
No
Not sure
Are you taking any medications for Lactose Intolerance?
*
Yes
No
Have you been diagnosed with Diverticulitis ?
*
Yes
No
Are you taking any medications for Diverticulitis?
*
Yes
No
Have you been diagnosed with Crohn's Disease?
*
Yes
No
Are you taking any medications for Crohn's Disease?
*
Yes
No
Have you been diagnosed with Gallstones?
*
Yes
No
Are you taking any medications for Gallstones?
*
Yes
No
Have you had a Hernia?
*
Current
Past
Not Applicable
Are you taking any medications for a Hernia?
*
Yes
No
Have you had a surgery to repair a Hernia?
*
Yes
No
Have you had a Gastric Bypass Procedure?
*
Yes
No
Are you taking any medications for Gastric Bypass Surgery?
*
Yes
No
Do you have Ulcers ?
*
Yes
No
Are you taking any medications for Ulcers?
*
Yes
No
Have you been diagnosed with Irritable Bowel Syndrome (IBS)?
*
Yes
No
Are you taking any medications for Irritable Bowel Syndrome (IBS)?
*
Yes
No
Have you been diagnosed with Celiac Disease?
*
Yes
No
Are you taking any medications for Celiac Disease?
*
Yes
No
Hepatitis – Infection type if known:
*
Write "N/A" if not applicable
Is Hepatitis Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Hepatitis?
*
Yes
No
Please describe "Other" Gastrointestinal Condition:
*
Write "N/A" if not applicable
Is "Other" Gastrointestinal Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Gastrointestinal Condition?
*
Yes
No
Metabolic/Endocrine Conditions
*
Hyperthyroidism
Hypothyroidism
Fatigue
Heat Intolerance
Cold Intolerance
Uncontrolled Weight Gain
Uncontrolled Weight Loss
Diabetes Type II
Diabetes Type I
Other
None
Please Describe "Other" Metabolic/Endocrine Condition:
*
Write "N/A" if not applicable
Have you been diagnosed with Hyperthyroidism?
*
Yes
No
Are you taking any medications for Hyperthyroidism?
*
Yes
No
Are you taking medications for Hypothyroidism?
*
Yes
No
Are you taking any medications for Hypothyroidism?
*
Yes
No
Do you have chronic Fatigue?
*
Yes
No
Are you taking any medications for Fatigue?
*
Yes
No
Do you have a Heat Intolerance?
*
Yes
No
Are you taking any medications for Heat Intolerance?
*
Yes
No
Do you have a Cold Intolerance?
*
Yes
No
Are you taking any medications for Cold Intolerance?
*
Yes
No
Have you experienced Uncontrolled Weight Gain recently?
*
Yes
No
Not sure
Are you taking any medications for Uncontrolled Weight Gain?
*
Yes
No
Have you experienced Uncontrolled Weight Loss recently?
*
Yes
No
Not sure
Are you taking any medications for Uncontrolled Weight Loss?
*
Yes
No
Have you been diagnosed with Diabetes Type II?
*
Yes
No
Are you taking any medications for Diabetes Type II?
*
Yes
No
Have you been diagnosed with Diabetes Type I?
*
Yes
No
Are you taking any medications for Diabetes Type I?
*
Yes
No
Is "Other" Metabolic/Endocrine Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Metabolic/Endocrine Condition?
*
Yes
No
Musculoskeletal Conditions
*
Chronic Regional Pain Syndrome (CRPS)
Fibromyalgia
Rheumatoid Arthritis
Osteoarthritis
Gout
Chronic Low Back Pain
Joint Pain (Hips, Knees, elbows, shoulders etc.)
Neck Pain
Muscle Pains
Artificial/Replacement Knee
Artificial/Replacement Hip
Joint swelling (Hips, Knees, elbows, shoulders etc.)
Other
None
Please describe "Other" Musculoskeletal Condition:
*
Write "N/A" if not applicable
Have you been diagnosed with CRPS?
*
Yes
No
Are you taking any medications for CRPS?
*
Yes
No
Have you been diagnosed with Fibromyalgia?
*
Yes
No
Are you taking any medications for Fibromyalgia?
*
Yes
No
Have you been diagnosed with Rheumatoid Arthritis?
*
Yes
No
Are you taking any medications for Rheumatoid Arthritis?
*
Yes
No
Have you been diagnosed with Osteoarthritis Ongoing?
*
Yes
No
Are you taking any medications for Osteoarthritis?
*
Yes
No
Have you been diagnosed with Gout?
*
Yes
No
Are you taking any medications for Gout?
*
Yes
No
Have you been diagnosed with Chronic Low Back Pain?
*
Yes
No
Are you taking any medications for Chronic Low Back Pain?
*
Yes
No
Have you been diagnosed with a Joint Pain?
*
Yes
No
Are you taking any medications for Joint Pain?
*
Yes
No
Have you been diagnosed with Neck Pain?
*
Yes
No
Are you taking any medications for Neck Pain?
*
Yes
No
Do you have Muscle Pains?
*
Yes – All the time
Yes - on and off
No
Are you taking any medications for Muscle Pains?
*
Yes
No
Have you had an Artificial Knee Replacement?
*
Yes
No
Are you taking any medications for Artificial Knee Replacement?
*
Yes
No
Have you had an Artificial Hip Replacement?
*
Yes
No
Are you taking any medications for Artificial Hip Replacement?
*
Yes
No
Do you have Joint Swelling?
*
Yes – All the time
Yes - on and off
No
Are you taking any medications for Joint Swelling?
*
Yes
No
Is "Other" Musculoskeletal Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Musculoskeletal Condition?
*
Yes
No
Respiratory Conditions
*
Asthma
Chronic Bronchitis
COPD
Cough
COVID-19
Cystic Fibrosis
Mesothelioma
Pneumonia (Past/Present/Current)
Tuberculosis (Positive Test)
Other
None
Please describe "Other" Respiratory Conditions:
*
Write "N/A" for not applicable
Do you have Asthma?
Yes
No
Are you taking any medications for Asthma?
*
Yes
No
Have you been diagnosed with Pneumonia?
*
Yes - present
Yes - past
No
Are you taking any medications for Pneumonia?
*
Yes
No
Have you had COVID-19?
*
Yes - present
Yes - past
No
Are you taking any medications for COVID-19?
*
Yes
No
Have you been diagnosed with Tuberculosis?
*
Yes
No
Are you taking any medications for Tuberculosis?
*
Yes
No
Have you been diagnosed with COPD?
*
Yes
No
Are you taking any medications for COPD?
*
Yes
No
Have you been diagnosed with Chronic Bronchitis?
*
Yes
No
Are you taking any medications for Chronic Bronchitis?
*
Yes
No
Have you been diagnosed with Cystic Fibrosis?
*
Yes
No
Are you taking any medications for Cystic Fibrosis?
Yes
No
Have you been diagnosed with Mesothelioma?
*
Yes
No
Are you taking any medications for Mesothelioma?
*
Yes
No
Do you have a Cough?
*
Yes - All the time
Yes - on and off
No
Are you taking any medications for Cough?
*
Yes
No
Have you been diagnosed with Sleep Apnea?
*
Yes
No
Is "Other" Respiratory Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Respiratory Conditions?
*
Yes
No
Neurological Conditions
*
Numbness/Tingling in Extremities
Intermittent Headaches
Migraines (Number per Month: _____)
Muscle weakness (Generalized/Intermittent/Exertion)
Epilepsy
Seizures (Type if known)
Lightheadedness/Dizziness (Intermittent/Constant)
Fainting
Stroke in Brain
Dementia
Alzheimer’s Disease
Muscular Dystrophy
Multiple Sclerosis
Parkinson’s Disease
Post-herpetic Neuralgia (Pain after Shingles)
Other
None
Seizures (Type if known)
*
Write "N/A" for not applicable
Migraines (Number per Month)
*
Write "N/A" for not applicable
Muscle weakness (Generalized/Intermittent/Exertion)
*
Generalized
Intermittent
Exertion
Not Applicable
Lightheadedness/Dizziness (Intermittent/Constant)
*
Intermittent
Constant
Not Applicable
Are you taking any medications for Lightheadedness/Dizziness?
*
Yes
No
Please describe "Other" Neurological Condition:
*
Write "N/A" for not applicable
Is Numbness/Tingling in Extremities Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Numbness/Tingling in Extremities?
*
Yes
No
Is Intermittent Headaches Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Intermittent Headaches?
*
Yes
No
Are Migraines Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Migraines?
*
Yes
No
Is Muscle Weakness Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Muscle Weakness?
*
Yes
No
Is Epilepsy Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Epilepsy?
*
Yes
No
Are Seizures Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Seizures?
*
Yes
No
Is Lightheadedness/Dizziness Ongoing Medical Condition?
*
Yes
No
Is Fainting Ongoing Medical Condition?
*
Yes
No
Is Stroke in Brain Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Stoke in Brain?
*
Yes
No
Have you been diagnosed with Dementia?
*
Yes
No
Are you taking any medications for Dementia?
*
Yes
No
Have you been diagnosed with Alzheimer's?
*
Yes
No
Are you taking any medications for Alzheimer's?
*
Yes
No
Have you been diagnosed with Muscular Dystrophy?
*
Yes
No
Are you taking any medications for Muscular Dystrophy?
*
Yes
No
Have you been diagnosed with Multiple Sclerosis?
*
Yyes
No
Are you taking any medications for Multiple Sclerosis?
*
Yes
No
Have you been diagnosed with Parkinson's Disease?
*
Yes
No
Are you taking any medications for Parkinson's Disease?
*
Yes
No
Is Post-Herpetic Neuralgia Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for Post-Herpetic Neuralgia?
*
Yes
No
Is "Other" Neurological Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Neurological Condition?
*
Yes
No
Hematological/Lymphatic Conditions
*
Coagulation Disorder
Anemia
Lymphoma (CA*)
Leukemia (CA*)
Myeloma (CA*)
Easy Bruising
Easy Bleeding (hemophilia)
Other
None
Please describe "Other" Hematological/Lymphatic Condition:
*
Write "N/A" for not applicable
Have you been diagnosed with a Coagulation Disorder?
*
Yes
No
Are you taking any medications for Coagulation Disorder?
*
Yes
No
Have you been diagnosed with Anemia?
*
Yes
No
Are you taking any medications for Anemia?
*
Yes
No
Have you been diagnosed with Lymphoma?
*
Yes
No
Are you taking any medications for Lymphoma?
*
Yes
No
Have you been diagnosed with Leukemia ?
*
Yes
No
Are you taking any medications for Leukemia?
*
Yes
No
Have you been diagnosed with Myeloma?
*
Yes
No
Are you taking any medications for Myeloma?
*
Yes
No
Do you have Bruise easily?
*
Yes
No
Are you taking any medications for Easy Bruising?
*
Yes
No
Have you been diagnosed with Hemophilia?
*
Yes
No
Are you taking any medications for Hemophilia?
*
Yes
No
Is "Other" Hematological/Lymphatic Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Hematological/Lymphatic Condition
*
Yes
No
Mental Health Conditions
*
Anxiety
Depression
Illicit Drug Use
Insomnia
Major Depressive Disorder (MDD)
Obsessive–Compulsive Disorder (OCD)
Postpartum Depression (PPD)
Posttraumatic Stress Disorder (PTSD)
Suicidal Thoughts (Ever)
Other
None
Have you been diagnosed with Anxiety?
*
Yes
No
Are you taking any medications for Anxiety?
*
Yes
No
Have you been diagnosed with Depression ?
*
Yes
No
Are you taking any medications for Depression?
*
Yes
No
Do you use Illicit Drug?
*
Yes - All the time
Yes - on and off
No
Have you been diagnosed with Insomnia?
*
Yes
No
Are you taking any medications for Insomnia?
*
Yes
No
Have you been diagnosed with Major Depressive Disorder?
*
Yes
No
Are you taking any medications for Major Depressive Disorder?
*
Yes
No
Have you been diagnosed with Obsessive Compulsive Disorder (OCD)?
*
Yes
No
Are you taking any medications for Obsessive Compulsive Disorder (OCD)?
*
Yes
No
Have you been diagnosed with Postpartum Depression (PPD)?
*
Yes
No
Are you taking any medications for Postpartum Depression (PPD)?
*
Yes
No
Have you been diagnosed with Post-Traumatic Stress Disorder (PTSD)?
*
Yes
No
Are you taking any medications for Post-Traumatic Stress Disorder (PTSD)?
*
Yes
No
Do you have Suicidal Thoughts?
*
Yes - All the time
Yes - on and off
No
Are you taking any medications for Suicidal Thoughts?
*
Yes
No
Please describe "Other" Mental Health Conditions:
*
Write "N/A" for not applicable
Is "Other" Mental Health Condition Ongoing Medical Condition?
*
Yes
No
Are you taking any medications for "Other" Mental Health Conditions?
*
Yes
No
Have you ever been sexually active?
*
Yes
No
Have you been sexually active in the last year?
*
Yes
No
Do you use contraception(s)?
*
Yes
No
Have you been vaccinated against HPV? Hepatitis A? Hepatitis B?
*
Write "N/A" for not applicable
Have you had an abnormal pap smear?
*
Yes
No
Abnormal Pap Smears Diagnosis
*
Write "N/A" for not applicable
Have you gone through Menapause?
*
Yes
No
Have you ever been pregnant?
*
Yes
No
Number of Pregnancies:
*
Write "N/A" for not applicable
Number of Vaginal Deliveries:
*
Write "N/A" for not applicable
Date(s) of Vaginal Deliveries:
*
Write "N/A" for not applicable
Number of C-sections:
*
Write "N/A" for not applicable
Date(s) of C-sections:
*
Write "N/A" for not applicable
Number of Miscarriages:
*
Write "N/A" for not applicable
Date(s) of miscarriages:
*
Write "N/A" for not applicable
Number of Abortions:
*
Write "N/A" for not applicable
Date(s) of abortions:
*
Write "N/A" for not applicable
Please use this section for additional explanations of current or past medical history:
*
Write "N/A" for not applicable
Do you have any Medication Allergies?
*
Yes
No
Do you have any Food Allergies
*
Yes
No
Do you have any Seasonal Allergies?
*
Yes
No
Alcohol Consumption:
*
Never
Past
Current
How Much Alcohol Consume Per Day & How Long
*
Write "N/A" for not applicable
Tobacco Usage:
*
Never
Past
Current
How Much Tobacco Per Day & How Long
*
Write "N/A" for not applicable
Have you ever had any problems with addiction?
*
Yes
No
Are addiction problems ongoing?
*
Yes
No
What is the addiction?
*
Write "N/A" for not applicable
What was the addiction and when did the problem resolve?
Write "N/A" for not applicable
Have you recently traveled out of the country?
*
Yes
No
By signing, I acknowledge that all information provided on this medical history intake is complete and accurate to my knowledge.
Signature
*
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