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Tell Us About Your Medical History
13
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HIPAA
Compliance
1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Today's Date
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Date
Year
Month
Day
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4
Age
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5
Birthday
-
Date
Year
Month
Day
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6
Sex
Male
Female
Intersex
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7
Allergies
YES
NO
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8
What are you allergic to?
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9
Please list current medications, including dose and number of times per day taken
ex: Metformin, 500 mg, 2x per day
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10
Please list current supplements, including dose and number of times per day taken
ex: Vitamin D, 50 mcg 1x per day
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11
Have you had any recent lab tests you'd like to discuss?
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12
Please share any previous lab test results you may have:
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13
Have you received any of the following diagnoses?
Alcoholism/Substance Abuse
Asthma
Anxiety
Bipolar
Cancer
Depression
Diabetes: Type 1
Diabetes: Type 2
Endometriosis
Emphysema (COPD)
Heart Disease
High Blood Pressure (hypertension)
High Cholesterol
Hyperthyroid/thyroid disease
Kidney Disease
Lupus
Migraine Headache
Overweight
Obesity
Polycystic Ovary Syndrome (PCOS)
Rheumatoid Arthritis
Stroke
Suicidal
Other
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14
Anything you'd like to tell us about these diagnosis? If you answered "Other," please specify here:
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