Blood Wellness Panel Form

Blood Wellness Panel Form
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name
Emergency Contact Number
Please enter a valid phone number.
Occupation
Employer
Primary Care Physician (PCP)

First NameLast Name
Physician Phone
Please enter a valid phone number.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Name
Preferred Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have known allergies / sensitivity to:

AdhesivesBenzyl AlcoholB VitaminsGLP-1 Receptor AgonistsLatexL-Carntine
Are you currently taking antibiotics?

YesNo
Do you take blood pressure medication(s)?

YesNo
Do you take any medication(s) that may cause increased risk of bleeding or delayed healing?

YesNo
Female Medical History

Currently PregnantTrying to ConceiveBreastfeedingPost-MenopauseBirth Control
Last Period Date
Pregnancies
Live Births
Male Medical History

VesectomyTrying To Conceive
General Medical History

Adrenal Fatigue/IssuesAnemia Blood DisordersAsthmaAutoimmune DisorderBlood Clotting DisorderCancerChemical DependenceCongestive Heart FailureDiabetes
General Medical History

DepressionDigestive IssuesGallbladder DiseaseEating DisorderHeart Disease / ArrhythmiaHigh Blood PressureHigh CholesterolImmune Deficiency
General Medical History

Intestinal IssuesKidney Disease / StonesLiver DiseaseMental Health DisorderNeurological DisorderPancreas DiseasePoor Wound HealingStroke / TIAsThyroid DiseaseUlcers (Gastric)
Please explain any of the above you checked "yes":
Do you consume alcohol?

YesNo
Drinks Per Week
Do you smoke?

YesNo
How many cigarettes and how often?
Current Weight
Prior Surgeries?
Current Medications?
Any medication allergies?
I affirm the information I have provided regarding my health, medication record, and prior surgeries is accurate to the best of my knowledge. I acknowledge that Magnum Bio Health is not responsible for any errors or incorrect information on this form.
Patient's Signature

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Patient's Full Name

First NameLast Name
Date

MonthDayYear
Date
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Blood Wellness Panel Form

I affirm the information I have provided regarding my health, medication record, and prior surgeries is accurate to the best of my knowledge. I acknowledge that Magnum Bio Health is not responsible for any errors or incorrect information on this form.