Patient Health History
Patient Information
Name
First Name, MI
Last Name
Nickname
What name would you like to be called?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Mobile Phone Number
Mobile Phone Carrier
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Age
Social Security Number
Today's Date
-
Month
-
Day
Year
Date
How would you like us to contact you?
Phone
Test Message / SMS
Email
I agree to receive text messages regarding appointments and future studies.
Yes
No
Height in Inches
Weight
Sex
Male
Female
Race
White/Caucasian
Black or African American
American Indian or Alaska Native
Native Hawaiian Other Pacific Islander
Asian / Indian
Other
Ethnicity
Non Hispanic / Latino
Hispanic / Latino
Other
Who referred you to us?
Back
Next
Emergency Contact Information
Emergency Contact Name
Emergency Phone Number
Emergency Contact Relationship
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Next
Medical History
Have you ever been treated for alcoholism?
Yes
No
If you have been treated for alcoholism, when were you treated?
Have you ever been treated for drug abuse?
Yes
No
If you have been treated for drug abuse, when were you treated?
Have you donated blood within the past 30 / 60 days?
Yes
No
If you have donated blood within the past 30 / 60 days, when did you donate blood?
Have you been diagnosed with COVID-19?
Yes
No
If you have been diagnosed with COVID-19, when were you diganosed?
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Next
Medical History - Habits
Do you consume caffeine: energy drinks, coffee, tablets?
Yes - Currently
Yes - Former
Never
How much caffeine do you consume in a day?
When did you start consuming caffeine?
-
Month
-
Day
Year
Date
When did you stop consuming caffeine?
-
Month
-
Day
Year
Date
Do you consume alcohol?
Yes - Currently
Yes - Former
Never
How much alcohol do you consume in a day?
When did you stop consuming alcohol?
-
Month
-
Day
Year
Date
When did you start consuming alcohol?
-
Month
-
Day
Year
Date
Do you smoke cigarettes?
Yes - Currently
Yes - Former
Never
How many packs of cigarettes do you smoke in a day?
When did you start smoking?
-
Month
-
Day
Year
Date
When did you stop smoking?
-
Month
-
Day
Year
Date
Do you smoke cigars or use chewing tobacco?
Yes - Currently
Yes - Former
Never
When did you start smoking cigars or using chewing tobacco?
-
Month
-
Day
Year
Date
When did you stop smoking cigars or using chewing tobacco?
-
Month
-
Day
Year
Date
Do you do use any of the following? If not, please select "none".
Pipe
Snuff
Vape
None
If you selected pipe/snuff/vape, please indicate if you are a former or current user:
Current
Former
Never
When did you start?
-
Month
-
Day
Year
Date
When did you stop?
-
Month
-
Day
Year
Date
Do you use marijuana in any form: smoking, pills, vaping, etc?
Yes - Current
Yes - Former
Never
When did you start?
-
Month
-
Day
Year
Date
When did you stop?
-
Month
-
Day
Year
Date
Back
Next
Medical History - Allergies
Please indicate if you have any of the following allergies, the date you discovered the allergy, and your reaction.
Aspirin / Tylenol / NSAIDS
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Codeine / Morphine
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Sulfa
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Mycins
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Penicillin
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Tetracycline
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Latex
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Egg Proteins
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Adverse reaction to any influenza vaccine?
Yes
No
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Other / Unlisted: Please specify the allergy
When did you discover the allergy?
-
Month
-
Day
Year
Date
What was your reaction?
Back
Next
Your Health - Skin Conditions
Please review these health conditions / disease, select "yes" or "no" as they relate to your health and provide the dates.
Hives
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Psoriasis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Eczema
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Sun Spots
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Rosacea
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Acne
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Eye Disorder / Disease
Please review these health conditions/diseases, select "yes" or "no" as they relate to your health and provide the dates.
Cataracts
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Glaucoma
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Dry Eyes
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Macular Degeneration
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diabetic Retinopathy
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Ear, Nose, & Throat
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Seasonal or Environmental Allergies
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Difficulty / Impaired Hearing
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Sinusitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Rhinitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Gastrointestinal
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Heartburn
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Ulcers
Yes
No
If yes - do you have bleeding ulcers?
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hernia
Yes
No
If yes - please specify the type of hernia(s):
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Irritable Bowel Syndrome
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Polyps?
Yes
No
If yes - please specify the polyp location
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hemorrhoids
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diverticulosis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
GERD
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Crohn's Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Inflammatory Bowel Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Chronic Diarrhea
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Constipation
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Opioid Induced Constipation
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Immunologic
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
HIV / AIDS
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Cancer
Yes
No
If yes - please specify type.
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Herpes Simplex
Yes
No
If yes - please specify oral or genital herpes simplex.
Oral
Genital
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Malaria
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition begin?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Neurological / Psychological
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Anxiety or Panic Attacks
Yes
No
If yes - please specify if you have been diagnosed with anxiety or panic attacks.
Anxiety
Panic Attacks
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Depression
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Insomnia
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Major Psychiatric Disorder
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Migraine Headaches
Yes
No
If yes - please specify if with vision disturbances / aura
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
General Headaches
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Seizure Disorder
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Cerebrovascular Accident (Stroke)
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
TIA
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diabetic Neuropathy
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Hepatic / Renal Urogenital / Gynecologic
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Kidney Stones
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Kidney / Urinary Tract Infection
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Overactive Bladder
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Liver Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hepatitis
Yes
No
If yes - please specify if you have Hepatitis A, B,or C.
Hepatitis A
Hepatitis B
Hepatitis C
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Benign Prostate Hypertrophy (BPH)
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Erectile Dysfunction
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Gynecological Disorder
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Postmenopausal
Yes
No
When was your last menstrual period?
-
Month
-
Day
Year
Date
Dysmenorrhea
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Amenorrhea
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Sexually Transmitted Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Kidney Disease
Yes
No
If yes - please specify which stage:
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hot Flashes
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition
Yes
No
Endometriosis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Respiratory
Asthma
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
Chronic Bronchitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
COPD
Yes
No
If yes - please specify if you use oxygen
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Emphysema
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Pneumonia
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Sleep Apnea
Yes
No
If yes - Do you use a machine?
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Tuberculosis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Back
Next
Your Health - Hematologic
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Clotting Disorder
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Chronic Anemia
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Phlebitis / Thrombophlebitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Back
Next
Your Health - Cardiovascular
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Angina
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Heart Murmur
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Heart Attack
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Irregular Heart Beat
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
High Blood Pressure
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
High Cholesterol / Triglycerides
Yes
No
Do you have High Cholesterol, High Triglycerides, or both?
High Cholesterol
High Triglycerides
Both
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Peripheral Vascular Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Coronary Artery Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Edema
Yes
No
If yes - please specify where
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
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Your Health - Endocrine
Please review these health conditions/disease, select "yes" or "no" as they relate to your health and provide the dates.
Diabetes
Yes
No
Please specify whether you have Type 1 or Type 2 Diabetes
Type 1
Type 2
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Low Blood Sugar
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hyperthyroidism
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Hypothyroidism
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Graves Disease
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your medical condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
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Your Health - Musculoskeletal
Osteoarthritis
Yes
No
If yes - please specify where.
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Rheumatoid Arthritis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Psoriatic Arthritis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Ankylosing Spondylitis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Lupus
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Fibromyalgia
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Cervical Pain
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Thoracic Back Pain
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Lumbar Pain
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Shoulder Pain
Yes
No
If yes - please specify which shoulder
Left
Right
Both
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Scoliosis
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Gout
Yes
No
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Degenerative Disc Disease
Yes
No
If yes - please specify location
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Other / Unlisted (Please specify your condition)
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
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Your Health - Other Medical Conditions
Are there any other past or current medical conditions not listed?
Yes
No
Diagnosis
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diagnosis
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diagnosis
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diagnosis
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diagnosis
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
Diagnosis
When did this condition begin?
-
Month
-
Day
Year
Date
When did this condition end?
-
Month
-
Day
Year
Date
Is this an ongoing condition?
Yes
No
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Your Health - Surgical / Hospitalization
Appendix
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Gall Bladder
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Cataract Repair
Yes
No
If yes - please specify: left, right, or both eyes.
Left
Right
Both
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Hernia Repair
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Prostate
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Vasectomy
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Hysterectomy
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Tonsillectomy
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Adenoidectomy
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Gastric Bypass or Sleeve
Yes
No
If yes - please specify which procedure was done
Bypass
Sleeve
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Breast Augmentation
Yes
No
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Other / Unlisted (Please specify)
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Other / Unlisted (Please specify)
Date
-
Month
-
Day
Year
Date
What caused the surgery/hospitalization?
Any planned surgery in the next 6 months?
Yes
No
Date
-
Month
-
Day
Year
Date
Please specify which procedure will be done
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Physician Information
Do we have permission to notify your primary care physician of your study participation?
Yes
No
I do not have a primary care physician
Current Physicians
Physician's Name
Specialty
Address
Phone Number
-
Area Code
Phone Number
Physician's Name
Specialty
Address
Phone Number
-
Area Code
Phone Number
Physician's Name
Specialty
Address
Phone Number
-
Area Code
Phone Number
Physician's Name
Specialty
Address
Phone Number
-
Area Code
Phone Number
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Family History
Please indicate if any of your family members have had or have any of the following:
Heart Problems
Yes
No
Family Member(s)
Cancer
Yes
No
Family Member(s)
Stroke
Yes
No
Family Member(s)
Diabetes
Yes
No
Family Member(s)
Other serious illnesses:
Yes
No
If yes - please specify the illness
Family Member(s)
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Litigation
Are you currently involved in any litigation regarding a medical condition or injury?
Yes
No
If yes - please explain
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Current Medications:
Prescriptions, Over-the-Counter Medications, Vitamins, and Herbal Supplements
Are you currently taking any other medications? This includes prescriptions, over-the-counter, vitamins and herbal supplements.
Yes
No
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
Medication
Why are you taking this medication?
Dosage?
How often are you taking this medication?
How are you taking this medication?
When did you start taking this medication?
-
Month
-
Day
Year
Date
When did (or will) you stop taking this medication?
-
Month
-
Day
Year
Date
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That's All!
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-
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Date
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