Medical History
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
What is your Gender?
*
Male
Female
Phone Number
*
-
Area Code
Phone Number
Check the conditions that apply to you now or previously
*
Arthritis
Fractures
Joint Replacement
Cancer
Heart disease
Diabetes
Hypertension
Kidney Disease
Cataracts
Anemia
Stomach Ulcers
Depression/Anxiety
Epilepsy/ Seizures
Thyroid problems
Stroke
Multiple Sclerosis
Acid reflux
Valley fever
Other
Past surgeries/operations
Check the symptoms that you're currently experiencing:
*
Weight gain
Weight loss
Fatigue/weakness
Fever
Eye redness/pain
Dry eyes
Dry mouth
Mouth/nose sores
Difficulty swallowing
Chest pain
Palpitations
Cough
Shortness of Breath
Coughing blood
Nausea/Vomiting
Abdominal pain
Change in bowel habits
Blood in urine
joint pain/stiffness
joint swelling
rash
hair loss
nail changes
Easy bruising tendency
Headaches
color changes of hands/feet in the cold
Tingling/numbness
Sleep problems
swollen glands
Anxiety/depression
Other
Does anyone in your family confirmed to have the following conditions?
Osteoarthritis
Rheumatoid arthritis
Systemic lupus
Sjogren's syndrome
Scleroderma
Osteoporosis
Hip Fractures
Gout
Ankylosing spondylitis
Psoriasis
Psoriatic arthritis
Polymyalgia rheumatica
Temporal arteritis
Vasculitis
Muscle problems
Eye inflammation
Ulcerative colitis
Crohn's disease
Other
Are you currently taking any medication?
*
Yes -list below
No
Do you have any medication allergies?
*
Yes
No
Not Sure
Preferred pharmacy name and phone number
Current medications
*
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Occasionally
Never
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
Do you use or have a history of using medical marijuana?
*
Please Select
Yes
No
Submit
Print Form
Should be Empty: