Clone of Dr. Wilcox NM Drop off Diagnostic Kit Order and Medical History Form

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Today's Date* This field is required.
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
What is your Gender?* This field is required.
Male
Female
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What is your height?* This field is required.
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How much do you weigh?* This field is required.
9
Social Security Number
10
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
In case of an emergency, notify:* This field is required.
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Emergency phone number* This field is required.
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How did you find out about us?* This field is required.
14
I certify that the information in this form is accurate
YESNO
15
By signing below, I verify the above information is true.* This field is required.
Clear
16
Describe in your own words your one Main Health Issue (not the diagnosis).* This field is required.
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If you have been given a diagnosis for this problem, what is it?* This field is required.
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When, specifically, did this problem begin?* This field is required.
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What types of treatment have you tried and was it helpful?* This field is required.
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To what extent does this problem interfere with your activities such as work, exercise, recreation, hobbies, sleep, sex?* This field is required.
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Please list in order of importance the Other Health Issues that concern you.
22
Please list all medications and health products you are currently taking. Include hormones, birth control pills, over the counter medications, dietary supplements, herbs, and homeopathic remedies.
23
Please list all medications and health products you are currently taking. Include hormones, birth control pills, over the counter medications, dietary supplements, herbs, and homeopathic remedies.
24
Please list all medications and health products you are currently taking. Include hormones, birth control pills, over the counter medications, dietary supplements, herbs, and homeopathic remedies.
25
List allergies to medications, supplements, chemicals and foods.* This field is required.
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List in chronological order by age when any significant health or medical condition occurred or started such as cancer,
27
Medical issues continued (in case you need to add more)
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Please list any significant medical problems that your parents, grandparents, siblings, aunts or uncles have/had that might
29
List all doctors and health providers you are currently working with.
30
ENERGY & GENERAL HEALTH:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Always fatigued
Fatigue easily
Sudden drop in energy
Chronic fatigue syndrome
Anemia
Adrenal fatigue, low cortisol
Low thyroid, hypothyroid
High thyroid, hyperthyroid
Perspire easily without exertion
Perspire with difficulty or not at all
Often thirsty
Seldom thirsty
High blood sugar
Diabetes
High blood pressure
Heart disease
Cancer
None
Other
31
GASTROINTESTINAL SYSTEM:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Constipation
Hard stool
Difficulty passing stool
Bowel movements feel incomplete
Frequent laxative use
Diarrhea
Loose stool
Erratic bowel movements
Foul smelling stool
Undigested food in stool
Blood in stool, black stool
Mucus in stool
Nausea
Vomiting
Indigestion (dyspepsia)
Gurgling noise in stomach
Irritable bowel syndrome
Crohn’s disease
Colitis or ulcerative colitis
Diverticulosis
Diverticulitis
Intestinal polyps
Intestinal gas, flatulence
Belching, burping
Unable to pass gas
Abdominal bloating
Abdominal pain or cramping
Stomach pain or cramping
Gastritis (stomach inflammation)
Stomach acidity
Heartburn, Acid reflux
GERD, gastroesophageal reflux
Ulcer
H. Pylori
Hiatal hernia
Bad breath
Bitter taste in mouth
Poor appetite
Weight loss
Excessive appetite
Weight gain
Intestinal parasites
SIBO (bacterial overgrowth)
Leaky gut (intestinal permeability)
Celiac disease
Gluten sensitivity
Food sensitivities, allergies
Hemorrhoids
Colon cancer
Gallstones
NONE
Other
32
How often do you have a bowel movement?
33
List any dietary restrictions.
34
Any other problems with your digestive system?
35
SLEEP:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Difficulty falling asleep
Difficulty staying asleep
Shallow sleep
Dream disturbed sleep
Nightmares
Wake at night thinking
Wake at night to urinate
Sleep too little
Prevented from getting sleep
Sleep too much
Narcolepsy
Difficulty waking in morning
Wake up not refreshed
Sleepy during the day
Need to take naps
Need to move limbs during sleep
Restless leg syndrome
Sleepwalking
Snoring
Sleep apnea
Sleep with mouth open
Sleep on a waterbed with heater
Sleep with an electric blanket
NONE
Other
36
How many hours do you usually sleep in 24 hours?
37
Any other sleep related problems?
38
IMMUNE SYSTEM ISSUES:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Frequent colds or flu
Recurrent fevers
Body aches
Chills
Night sweats
Mononucleosis
Hepatitis
HIV
Long COVID
NONE
Other
39
Any other problems with your immune system?
40
AUTOIMMUNE DISORDERS:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Rheumatoid Arthritis
Type 1 Diabetes
Lupus
Multiple Sclerosis
Myasthenia Gravis
Hashimoto’s Thyroiditis
Graves’ Disease
Celiac Disease
Inflammatory Bowel Disease
Crohn’s disease
Psoriasis
Psoriatic arthritis
Scleroderma
Ankylosing spondylitis
Sjogren’s syndrome
Guillain-Barré syndrome
Vasculitis
Pemphigus
NONE
Other
41
Any other problems autoimmune issues?
42
LUNGS:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Chest cold
Chronic cough
Dry cough
Tight rattling cough
Loose productive cough
Cough, thick, sticky, colored phlegm
Cough, thin, watery, clear phlegm
Cough up blood
Bronchitis, acute
Bronchitis, chronic
Pneumonia
Influenza, flu
Emphysema
COPD
Asthma
Shortness of breath
Wheezing
Tuberculosis
Valley Fever, Coccidioidomycosis
Sarcoidosis
Lung cancer
Lung pain
NONE
Other
43
Any other problems with your lungs or breathing?
44
EARS, NOSE, THROAT:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Head cold
Congestion in ears
Earache
Ear infection
Ringing in the ears, tinnitus
Hearing impairment
Vertigo, dizziness
Meniere’s disease
Pressure in ears
Perforated eardrum
Hearing loss
Excessive ear wax
Deafness
Frequent colds
Nasal congestion
Runny nose
Sneezing
Allergies
Sinus congestion or pain
Sinusitis or sinus infection
Nose bleeds
Facial pain
Decreased sense of smell
No sense of smell
Difficulty swallowing
Lump or pit in throat
Sore throat
Strep throat
Tonsillitis
Swollen lymph nodes in neck
Dry mouth
Excessive saliva or drooling
Sores in mouth
Cold sores or fever blisters (HSV1)
Sores around lips
Chapped of cracked lips
Bad taste in mouth
Burning sensation in mouth
Geographic tongue
Sores on tongue
Center crack in tongue
Cracks in tongue
Scalloped edges on tongue
Pale tongue
Red tongue
Purple or dark tongue
Dry tongue
Thin white coat on tongue
Thick creamy coat on tongue
Red spots on tongue
Unable to produce saliva
Bad breath
NONE
Other
45
Any other problems with your ears, nose, or throat?
46
DENTAL & MOUTH:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Tooth ache
Tooth sensitivity
Dental abscess, infected tooth
Cavities, tooth decay
Chipped tooth
Cracked, broken tooth
Loose tooth
Tooth loss
Impacted tooth
Crooked teeth, misalignment
Wisdom teeth issues
Gum disease
Periodontitis, gingivitis
Bleeding gums
Mouth ulcers
Herpes
Clenching, grinding teeth
Jan tension, TMJ
Dry mouth
Bad breath, halitosis
Bad taste in mouth
Metallic taste in mouth
Dentures
Oral cancer
NONE
Other
47
How many “silver” mercury amalgam dental fillings?
48
Root Canals? Crowns? Bridges?
49
Any other problems with your teeth or mouth?* This field is required.
Pressure
Cold
Heat
Sweets
NONE
Other
50
Any other problems with your teeth or mouth?
51
SKIN HAIR & NAILS:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Rashes
Hives
Itching
Eczema
Psoriasis
Shingles (herpes zoster)
Herpes simplex virus 1 (HSV1) - oral
Herpes simplex virus 2 (HSV2)
Pimples or acne
Boils
Ulcerations or sores
Infections or inflammations
Recent moles
Recent change in mole
Warts
Dry skin
Cracked skin on fingers
Moist palms
Moist feet
Fungus on skin
Hair loss
Dandruff
Dry hair
Pale lusterless nails
Lengthwise ridges on nails
Crosswise ridges on nails
White spots on nails
Thick nails
Fungus under nails
Split nails
Weak, brittle or flaking nails
Clubbing (convex) nails
Spooning (thin & concave) nails
No moons
Large moons
Nail biting
NONE
Other
52
Any other problems with your skin or hair?
53
CARDIOVASCULAR SYSTEM:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Palpitations
Rapid heartbeat
Too strong heartbeat
Arrhythmia
Irregular heartbeat
Atrial fibrillation (Afib)
Mitral valve prolapse
Angina, chest pain or pressure
Pain in chest, back, jaw, neck, arm
Shortness of breath
Coronary artery disease
Congestive heart failure
Diabetes
Heart attack/myocardial infarction
Lightheadedness, dizziness
Nausea, vomiting, cold sweats
Heart disease
Vascular disease
Atherosclerosis, plaque buildup
Anemia
Hard calcium plaque buildup
Soft plaque buildup
Heart bypass surgery
Angioplasty, coronary artery stent
Stents in other arteries
Heart Surgery
Family history of heart disease
High blood pressure, hypertension
Low blood pressure
Stroke
Sudden numbness or weakness
Sudden blurred or lost vision
Slurred speech
Blood clots
Phlebitis
Varicose veins
Bruise easily
Hemophilia
Edema
Swelling feet or legs
Swelling of hands or arms
Cold hands
Cold feet
Hot hands or palms
Hot feet or soles
Too cold generally
Too hot generally
Rheumatic fever
Current smoker
Former smoker
Sedentary lifestyle
Overweight
Blackouts or fainting
Slow heartbeat
High cholesterol
High triglycerides
Blood transfusion
NONE
Other
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What is your blood type?* This field is required.
A pos
A neg
AB pos
AB neg
B pos
B neg
O pos
O neg
Other
55
Any other problems with your heart or circulation?
56
NEUROLOGICAL SYSTEM & HEAD:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Dizziness or loss of balance
Seizures or epilepsy
Poor memory
Alzheimer’s
Dementia
Parkinson’s
Amyotrophic lateral sclerosis (ALS)
Multiple sclerosis
Lack of reflex
Unusual lack of coordination
Migraine headache
Cluster headache
Headache
Concussion
Traumatic brain injury
NONE
Other
57
If you have numbness or abnormal sensation, where is it?
58
Any other problems with your head or neurological system?
59
EYES:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Nearsighted (myopia)
Farsighted (hyperopia)
Astigmatism
Glaucoma
Cataracts
Macular degeneration
Double vision
Poor night vision
Sensitivity to light
Blurred vision
Floating spots
Pressure behind eyes
Eye pain
Dry eyes
Watery eyes
Itchy eyes
Red eyes
Conjunctivitis
Need eyeglasses
Diminishing vision
Blindness
NONE
Other
60
Any other problems with your eyes?
61
MUSCULOSKELATAL SYSTEM:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Neck pain or stiffness
Shoulder blade pain
Shoulder joint pain or stiffness
Rotator cuff tear or syndrome
Upper arm pain or stiffness
Elbow pain or stiffness
Wrist pain or stiffness
Carpal tunnel syndrome
Numbness or tingling in hands
Hand or finger pain or stiffness
Upper back pain or stiffness
Mid back pain or stiffness
Low back pain or stiffness
Scoliosis
Sacroiliac pain or stiffness
Hip joint pain or stiffness
Pain into thigh or upper leg
Pain into calf or lower leg
Weak legs
Knee pain or stiffness
Weak knees
Leg or calf cramping
Restless leg syndrome
Ankle pain or stiffness
Weak ankles
Plantar faciitis, heal pain
Foot or toe pain or stiffness
Numbness or tingling in feet
Muscle spasms or cramps
Muscle weakness
Paralysis
Stiff all over
Osteoarthritis
Rheumatoid arthritis
Osteopenia
Osteoporosis
Tendonitis
Fibromyalgia
NONE
Other
62
If you have osteoarthritis or rheumatoid arthritis, what joints are affected?
63
If you have pain other than above, where is it located
64
URINARY TRACT SYSTEM:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Scanty or small amount of urine
Dark urine
Strong smelling urine
Cloudy urine
Excessive amount of urine
Clear urine
Unable to hold urine
Urgency to urinate
Persistent urge to urinate
Frequent urination
Difficulty urinating
Decreased flow of urine
Flow does not stop quickly
Dribbling
Bed wetting
Pain or burning when urinating
Pain or discomfort in bladder area
Blood in urine
Bladder infection
Kidney infection
Kidney stones
Kidney disease
Sores on genitals
Herpes simplex virus 2
Night sweats
Hot feet while sleeping
NONE
Other
65
How many times do you urinate in 24 hours?
66
How many times do you wake at night to urinate?
67
Any other problems with your urinary system or genitals?
68
ENDOCRINE SYSTEM & HORMONES:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Type 1 diabetes
Type 2 diabetes
High blood sugar, insulin resistance
Hypoglycemia
Hypothyroid
Hyperthyroid
Grave’s disease
Hashimoto’s thyroiditis
Goiter
Adrenal insufficiency, fatigue
Addison’s disease
Cushing’s syndrome (high cortisol)
Polycystic ovary syndrome (PCOS)
Growth hormone problems
Pituitary disorder
Parathyroid disorder
Acromegaly
NONE
Other
69
Any other problems with your endocrine system or hormones?
70
MALE GENITALS:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Enlarged prostate, benign (BHP)
Prostatitis
Prostate cancer
Low sperm count
Erectile dysfunction (ED)
Inability to achieve an erection
Inability to maintain an erection
Inability to achieve orgasm
Premature ejaculation
Ejaculation during sleep
Pain/discomfort during intercourse
Low libido, sexual energy
Excessive sexual energy
Priaprism (persistent erection)
Peyronie’s disease
NONE
Other
71
Any other problems with your genitals?
72
FEMALE GENITALS & PREGNANCY:Please fill in any inputs that apply.
73
FEMALE GENITALS & PREGNANCY:Please fill in any inputs that apply.
74
FEMALE GENITALS & PREGNANCY:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Have not begun to menstruate
Hysterectomy
Hot flashes
Night sweats
Vaginal dryness
Sleep disturbances
Emotional sensitivity
Pain/discomfort during intercourse
Inability to achieve orgasm
Low sexual energy
Excessive sexual energy
Irregular menstrual cycle
Heavy flow
Light flow
Clots
Dark or brownish blood
Light colored or pale blood
Painful periods
Cramping before start of period
Cramping after start of period
Low back ache with period
Spotting between periods
Missed periods
PMS
Premenstrual fluid retention
Premenstrual headache
Premenstrual constipation
Premenstrual diarrhea
Premenstrual emotional sensitivity
Premenstrual bloating
Premenstrual breast sensitivity
Breast sensitivity during period
Midcycle breast sensitivity
Currently have an IUD
Previously had an IUD
Vaginal discharge – no odor
Vaginal discharge – foul smelling
Vaginal discharge – brownish
Vaginal discharge, white, curd-like
Vaginal discharge, frothy, profuse
Vaginal discharge, itchy
Vaginal discharge, burning
Abnormal PAP
Uterine fibroids or cysts
Ovarian cysts
Breast sensitivity
Breast cysts or lumps
Fibrocystic breasts
Premenstrual irritability
Pelvic inflammatory disease
Endometriosis
Ovarian cancer
Uterine cancer
Infertility
Cannot maintain pregnancy
Trying to become pregnant
Pregnant
Nursing
Nausea or morning sickness
Polycystic ovary syndrome (PCOS)
NONE
Other
75
Any other problems with your genitals or pregnancy?
76
PSYCHOLOGY:* This field is required.Check all the conditions that apply to you. Make sure you scroll down to answer all questions and everything is laid out to read from left to right, top to bottom.
Tend to repress motions
Overly emotional
Mood swings
Frequently irritated or angry
Difficulty relaxing
Indecisiveness
Foggy headed
Mental cloudiness
Lack of mental clarity
Impaired cognition
Difficulty concentrating
Confusion
Depression
Lowered mood
Loss of interest & enjoyment
Lack of motivation
Lower energy
Sadness, grief
Frequent crying
Anxiety, fear
Difficulty handling stress
Social phobias
Panic disorder
Claustrophobia
Agoraphobia
Other specific phobias
Intrusive thoughts and impulses
Obsessive compulsive disorder (OCD)
Post-traumatic stress disorder (PTSD)
Attention deficit hyperactivity disorder (ADHD)
Difficulty concentrating
Dissociative disorder
Eating disorder
Anorexia
Bulimia nervosa
Binge eating
Bipolar affective disorder
Mania (elation)
Paranoia
Confused thinking
Delusions
Hallucinations
Psychosis
Schizophrenia
History of suicidal thoughts
NONE
Other
77
Have you recently had an unusually stressful experience such as divorce, loss of job, severe illness, death?
78
Is there a constant stress in your life at work, with your family, with your friends, with finances?
79
Generally, how would you rate your stress level?* This field is required.
Low
Moderate
High
Other
80
Have you ever been attacked?
YESNO
81
Have you ever been abused?* This field is required.
Physically
Mentally
Sexually
I have not been abused
Other
82
Any other psychological or emotional concerns?
83
Please describe how you feel about the following. Use an “S” for Satisfying, “A” for Acceptable and “P” if it might be a Problem area.
84
Describe problem areas.
85
Have you ever had a problem with alcohol or drugs?
YESNO
86
If you drink alcohol, what do you drink, how much and how often?
87
Do you smoke cigarettes, or vape?
YESNO
88
If you do smoke or vape, how much and how often?
89
Do you exercise regularly?
YESNO
90
Describe your exercise?
91
Describe the work you do or did if you are retired.
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Where have you traveled outside of the US?
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If you have had an unusual exposure to a toxic substance or radiation, describe what and when?
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Use the following space to add anything else you think might be important.
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