Medical History Intake
Please select which state you are interested in?(Required)
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Arizona
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Indiana
Massachusetts
Email(Required)
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Best Contact Number
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Please enter a valid phone number.
Name
First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender(Required)
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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
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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
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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?
Immunological Conditions
AIDS/HIV
Allergies
Autoimmune Disease (RA, Lupus, etc.)
Rheumatic Fever
Other
Is AIDS/HIV Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for AIDs/HIV?
Yes
No
Is Rheumatic Fever Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Rheumatic Fever?
Yes
No
Are Allergies Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Allergies?
Yes
No
Is Autoimmune Disease Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Autoimmune Disease?
Yes
No
Please describe "Other" Immunological Condition:
Is "Other" Immunological Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for "Other" Immunological Condition?
Yes
No
Cardiovascular Conditions
Angina (Chest Pain)
Bleeding Problems
Blood Clots
Bypass Surgery
Congestive 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
Is Angina Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Angina?
Yes
No
Is CHF Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications related to CHF?
Yes
No
Is High Blood Pressure Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for High Blood Pressure?
Yes
No
Is Shortness of Breath Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Shortness of Breath?
Yes
No
Is Low Blood Pressure Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Low Blood Pressure?
Yes
No
Is High Cholesterol Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for High Cholesterol?
Yes
No
Is TIA Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for TIA?
Yes
No
Are Blood Clots Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Blood Clots?
Yes
No
Are Bleeding Problems Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Bleeding Problems?
Yes
No
Is Heart Attack Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
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 – Condition is ongoing
No – Condition has resolved
Are you taking any medications for PAD?
Yes
No
Are you taking any medications related to Pacemaker?
Yes
No
Is Irregular Heartbeat Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Irregular Heartbeat?
Yes
No
Is Fainting Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Fainting?
Yes
No
Please describe Other:
Is "Other" Cardiovascular Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
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
Please describe skin cancer type and location:
Is Skin Cancer Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Skin Cancer?
Yes
No
Is AK Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for AK?
Yes
No
Is Eczema Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Eczema?
Yes
No
Is Psoriasis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Psoriasis?
Yes
No
Is Scarring Acne Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Scarring Acne?
Yes
No
Is HS Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for HS?
Yes
No
Is Rosacea Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Rosacea?
Yes
No
Is Shingles Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Shingles?
Yes
No
Is or was your diabetic foot ulcer on your:
Right foot
Left foot
Both feet
Is Diabetic Foot Ulcer Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Diabetic Foot Ulcer?
Yes
No
Is Pressure Ulcer Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Pressure Ulcer?
Yes
No
Is Rash Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Rash?
Yes
No
Please describe Other Dermatological Conditions:
Is "Other" Dermatological Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
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
Are Allergies/Sinusitis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Allergies/Sinusitis?
Yes
No
Is Hearing Loss Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Hearing Loss?
Yes
No
Is Ear Pain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Ear Pain?
Yes
No
Is Dizziness Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Dizziness?
Yes
No
Is Nasal Congestion Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Nasal Congestion?
Yes
No
Is Hoarseness Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Hoarseness?
Yes
No
Is Sinus Pressure Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Sinus Pressure?
Yes
No
Is Snoring/Apnea Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Snoring/Apnea?
Yes
No
Is Throat Pain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Throat Pain?
Yes
No
Please describe "Other" ENT Conditions:
Is "Other" ENT Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
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
Is Urinary Frequency Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Urinary Frequency?
Yes
No
Is Burning with Urination Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Burning with Urination?
Yes
No
Is Blood in Urine Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Blood in Urine?
Yes
No
Is Problems Urinating Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Problems Urinating?
Yes
No
Are Problems with Sex Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Problems with Sex?
Yes
No
Type of sexually transmitted infection, if known:
Are Sexually Transmitted Infection Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Sexually Transmitted Infection?
Yes
No
Is BPH Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for BPH?
Yes
No
Are Kidney Stones Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Kidney Stones?
Yes
No
Are Kidney Problems Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Kidney Problems?
Yes
No
Please describe "Other" Genitourinary Condition:
Is "Other" Genitourinary Conditions Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
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
Is Nausea Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Nausea?
Yes
No
Is GERD Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for GERD?
Yes
No
Vomiting (Single Episode/Constant)
Single Episode
Constant
Is Vomiting Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Vomiting?
Yes
No
Constipation (Intermittent/Chronic)
Intermittent
Chronic
Is Constipation Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Constipation?
Yes
No
Is Abdominal Pain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Abdominal Pain?
Yes
No
Is Diarrhea Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Diarrhea?
Yes
No
Is Blood in Stool Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Blood in Stool?
Yes
No
Is Lactose Intolerance Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Lactose Intolerance?
Yes
No
Is Diverticulitis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Diverticulitis?
Yes
No
Is Crohn's Disease Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Crohn's Disease?
Yes
No
Is Gallstones Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Gallstones?
Yes
No
Is Hernia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Hernia?
Yes
No
Is Gastric Bypass Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Gastric Bypass Surgery?
Yes
No
Are Ulcers Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Ulcers?
Yes
No
Is Irritable Bowel Syndrome (IBS) Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Irritable Bowel Syndrome (IBS)?
Yes
No
Is Celiac Disease Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Celiac Disease?
Yes
No
Hepatitis – Infection type if known:
Is Hepatitis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Hepatitis?
Yes
No
Please describe "Other" Gastrointestinal Condition:
Is "Other" Gastrointestinal Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
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
Please Describe "Other" Metabolic/Endocrine Condition:
Is Hyperthyroidism Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Hypothyroidism Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Fatigue Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Heat Intolerance Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Cold Intolerance Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Uncontrolled Weight Gain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Uncontrolled Weight Loss Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Diabetes Type II Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Diabetes Type I Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is "Other" Metabolic/Endocrine Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Hyperthyroidism?
Yes
No
Are you taking any medications for Hypothyroidism?
Yes
No
Are you taking any medications for Fatigue?
Yes
No
Are you taking any medications for Heat Intolerance?
Yes
No
Are you taking any medications for Cold Intolerance?
Yes
No
Are you taking any medications for Uncontrolled Weight Gain?
Yes
No
Are you taking any medications for Uncontrolled Weight Loss?
Yes
No
Are you taking any medications for Diabetes Type II?
Yes
No
Are you taking any medications for Diabetes Type I?
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
Please describe "Other" Musculoskeletal Condition:
Is CRPS Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Fibromyalgia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Rheumatoid Arthritis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Osteoarthritis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Gout Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Chronic Low Back Pain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Joint Pain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Neck Pain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are Muscle Pains Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Artificial Knee Replacement Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Artificial Hip Replacement Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Joint Swelling Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is "Other" Musculoskeletal Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for CRPS?
Yes
No
Are you taking any medications for Fibromyalgia?
Yes
No
Are you taking any medications for Rheumatoid Arthritis?
Yes
No
Are you taking any medications for Osteoarthritis?
Yes
No
Are you taking any medications for Gout?
Yes
No
Are you taking any medications for Chronic Low Back Pain?
Yes
No
Are you taking any medications for Joint Pain?
Yes
No
Are you taking any medications for Neck Pain?
Yes
No
Are you taking any medications for Muscle Pains?
Yes
No
Are you taking any medications for Artificial Knee Replacement?
Yes
No
Are you taking any medications for Artificial Hip Replacement?
Yes
No
Are you taking any medications for Joint Swelling?
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
Pneumonia (Past/Present/Current)
Past
Present
Current
Please describe "Other" Respiratory Conditions:
Is Asthma Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Pneumonia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is COVID-19 Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Tuberculosis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is COPD Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Chronic Bronchitis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Cystic Fibrosis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Mesothelioma Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Cough Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is "Other" Respiratory Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Asthma?
Yes
No
Are you taking any medications for Pneumonia?
Yes
No
Are you taking any medications for Tuberculosis?
Yes
No
Are you taking any medications for COVID-19?
Yes
No
Are you taking any medications for COPD?
Yes
No
Are you taking any medications for Chronic Bronchitis?
Yes
No
Are you taking any medications for Cystic Fibrosis?
Yes
No
Are you taking any medications for Mesothelioma?
Yes
No
Are you taking any medications for Sleep Apnea?
Yes
No
Are you taking any medications for Cough?
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
Seizures (Type if known)
Migraines (Number per Month)
Muscle weakness (Generalized/Intermittent/Exertion)
Generalized
Intermittent
Exertion
Lightheadedness/Dizziness (Intermittent/Constant)
Intermittent
Constant
Please describe "Other" Neurological Condition:
Is Numbness/Tingling in Extremities Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Intermittent Headaches Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are Migraines Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Muscle Weakness Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Epilepsy Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are Seizures Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Lightheadedness/Dizziness Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Fainting Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Stroke in Brain Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Dementia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Alzheimer's Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Muscular Dystrophy Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Multiple Sclerosis Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Parkinson's Disease Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Post-Herpetic Neuralgia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is "Other" Neurological Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Numbness/Tingling in Extremities?
Yes
No
Are you taking any medications for Intermittent Headaches?
Yes
No
Are you taking any medications for Migraines?
Yes
No
Are you taking any medications for Muscle Weakness?
Yes
No
Are you taking any medications for Epilepsy?
Yes
No
Are you taking any medications for Seizures?
Yes
No
Are you taking any medications for Lightheadedness/Dizziness?
Yes
No
Are you taking any medications for Fainting?
Yes
No
Are you taking any medications for Stoke in Brain?
Yes
No
Are you taking any medications for Dementia?
Yes
No
Are you taking any medications for Alzheimer's?
Yes
No
Are you taking any medications for Muscular Dystrophy?
Yes
No
Are you taking any medications for Multiple Sclerosis?
Yes
No
Are you taking any medications for Parkinson's Disease?
Yes
No
Are you taking any medications for Post-Herpetic Neuralgia?
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
Please describe "Other" Hematological/Lymphatic Condition:
Is Coagulation Disorder Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Anemia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Lymphoma Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Leukemia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Myeloma Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Easy Bruising Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is Hemophilia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Is "Other" Hematological/Lymphatic Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Coagulation Disorder?
Yes
No
Are you taking any medications for Anemia?
Yes
No
Are you taking any medications for Lymphoma?
Yes
No
Are you taking any medications for Leukemia?
Yes
No
Are you taking any medications for Myeloma?
Yes
No
Are you taking any medications for Easy Bruising?
Yes
No
Are you taking any medications for Hemophilia?
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
Is Anxiety Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Anxiety?
Yes
No
Is Depression Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Depression?
Yes
No
Is Illicit Drug Use Ongoing?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Illicit Drug Use?
Yes
No
Is Insomnia Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Insomnia?
Yes
No
Is Major Depressive Disorder Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Major Depressive Disorder?
Yes
No
Is Obsessive Compulsive Disorder (OCD) Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Obsessive Compulsive Disorder (OCD)?
Yes
No
Is Postpartum Depression (PPD) Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Postpartum Depression (PPD)?
Yes
No
Is Post-Traumatic Stress Disorder (PTSD) Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Post-Traumatic Stress Disorder (PTSD)?
Yes
No
Are Suicidal Thoughts Ongoing?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for Suicidal Thoughts?
Yes
No
Please describe "Other" Mental Health Conditions:
Is "Other" Mental Health Condition Ongoing Medical Condition?
Yes – Condition is ongoing
No – Condition has resolved
Are you taking any medications for "Other" Mental Health Conditions?
Yes
No
Have you been sexually active in the last year?
Yes
No
Have you ever been sexually active?
Yes
No
Do you use contraceptions?
Yes
No
Have you been vaccinated against HPV? Hepatitis A? Hepatitis B?
Have you had an abnormal pap smear?
Yes
No
Abnormal Pap Smears Diagnosis
Menapause?
Yes
No
Have you ever been pregnant?
Yes
No
Number of Pregnancies:
Number of Vaginal Deliveries:
Date(s) of Vaginal Deliveries:
Number of C-sections:
Date(s) of C-sections:
Number of Miscarriages:
Date(s) of miscarriages:
Number of Abortions:
Date(s) of abortions:
Please use this section for additional explanations of current or past medical history:
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
Tobacco Usage:
Never
Past
Current
How Much Tobacco Per Day & How Long
Have you ever had any problems with addiction?
*
Yes
No
Are addiction problems ongoing?
Yes
No
What is the addiction?
What was the addiction and when did the problem resolve?
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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