• LawsOnHealth Wellness, LLC

    Dr. Lesa Lawson, ND, CHHC, AADP
  • Health History Questionnaire

    Confidential
  •  -  - Pick a Date
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  •  -
  • Vitals

  • End - Vitals

  • Lifestyle/General Habits

  • Note

    Note: Some questions may be repeated, as they apply to different body systems.
  • Thyroid/Parathyroid (Glandular System)

  • End - Thyroid/Parathyroid (Glandular System)

  • Pancreas


  • End - Pancreas

  • Adrenal Glands

  • Medulla (Adrenal)

  • Cortex (Adrenal)


  • End - Adrenal Glands

  • Females Only

  • End of 'Females-Only' Section

  • Males Only

  • End of 'Males-Only' Section

  • Gastro-Intestinal Tract

  • End - Gastro-Intestinal Tract

  • Liver/Gallbladder/Blood

  • End - Liver/Gallbladder/Blood

  • Heart and Circulation

  • End - Heart and Circulation

  • Skin

  • End - Skin

  • Lymphatic System

  • End - Lymphatic System

  • Kidneys and Bladder

  • End - Kidneys and Bladder

  • Lungs

  • End - Lungs

  • Environmental Toxins

  • End - Environmental Toxins

  • Chemical Medications

    List all medications you are currently taking
  • Genetic/Family Medical History

  • You are nearing the end.

  • Thank you!

  • ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPPA PRIVACY ACT - CONFIDENTIAL / HIPPA APPROVED FORM

    NOTICE OF PRIVACY PRACTICES

    The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us, and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

    LawsOnHealth Wellness, LLC

    I understand the Notice of Privacy Practices

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