Medical History

Medical History

What is your estimate of your general health?

Do You Have or Have You Ever Had:

1. hospitalization for illness or injury
31. head or neck injuries
2. an allergic reaction to
6. pacemaker or implantable defibrillator
3. heart problems, or cardiac stent within the last six months
33. neurologic disorders (ADD/ADHD, prion disease)
4. history of infective endocarditis
34. viral infections and cold sores
5. artificial heart valve, repaired heart defect (PFO)
35. any lumps or swelling in the mouth
6. pacemaker or implantable defibrillator
36. hives, skin rash, hay fever
7. orthopedic implant (joint replacement)
37. STI / STD / HPV
8. rheumatic or scarlet fever
38. hepatitis
9. high or low blood pressure
39. HIV / AIDS
10. a stroke (taking blood thinners)
40. tumor, abnormal growth
11. anemia or other blood disorder
41. radiation therapy
12. prolonged bleeding due to a slight cut (INR > 3.5)
42. chemotherapy, immunosuppressive medication
13. emphysema, shortness of breath, sarcoidosis
43. emotional difficulties
14. tuberculosis, measles, chicken pox
44. psychiatric treatment
15. asthma
45. antidepressant medication
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
46. alcohol / recreational drug use
17. kidney disease

Are You:

18. liver disease
47. presently being treated for any other illness
19. jaundice
47. presently being treated for any other illness
20. thyroid, parathyroid disease, or calcium deficiency
48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
21. hormone deficiency
49. taking medication for weight management
22. high cholesterol or taking statin drugs
50. taking dietary supplements
23. diabetes
51. often exhausted or fatigued
24. stomach or duodenal ulcer
52. experiencing frequent headaches
25. digestive disorders (i.e. celiac disease, gastric reflux)
53. a smoker, smoked previously or use smokeless tobacco
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
54. considered a touchy / sensitive person
27. arthritis
55. often unhappy or depressed
28. autoimmune disease
56. taking birth control pills
29. glaucoma
57. currently pregnant
30. contact lenses
58. prostate disorders
List all medicatons, supplements, and or vitamins taken within the last two years.
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.