MEDICAL HISTORY
What is your estimate of your general health?

DO YOU HAVE or HAVE YOU EVER HAD:

1. Hospitalization for illness or injury YesNo
2. An allergice reaction to YesNo
Aspirin, ibuprofen, acetaminophen, codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Fluoride
Metals (nickel, gold, silver, other)
Latex
3. Heart problems, or cardiac stent within the last six months YesNo
4. History of infective endocarditisYesNo
5. Artificial heart valve, repaired heart defect (PFO)YesNo
6. Pacemaker or implantable defibrillatorYesNo
7. Orthopedic implant (joint replacement)YesNo
8. Rheumatic or scarlet feverYesNo
9. High or low blood pressureYesNo
10. A stroke (taking blood thinners)YesNo
11. Anemia or other blood disorderYesNo
12. Prolonged bleeding due to a slight cut (INR > 3.5)YesNo
13. Emphysema, shortness of breath, sarcoidosisYesNo
14. Tuberculosis, measles, chicken poxYesNo
15. AsthmaYesNo
16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)YesNo
17. Kidney diseaseYesNo
18. Liver diseaseYesNo
19. JaundiceYesNo
20. Thyroid, parathyroid disease, or calcium deficiencyYesNo
21. Hormone deficiencyYesNo
22. High cholesterol or taking statin drugs YesNo
23. Diabetes YesNo
24. Stomach or duodenal ulcerYesNo
25. Digestive disorders (i.e. celiac disease, gastric refluxYesNo
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)YesNo
27. ArthritisYesNo
28. Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)YesNo
29. GlaucomaYesNo
30. Contact lensesYesNo
31. Head or neck injuriesYesNo
32. Epilepsy, convulsions (seizures)YesNo
33. Neurologic disorders (ADD/ADHD, prion disease)YesNo
34. Viral infections and cold soresYesNo
35. Any lumps or swelling in the mouthYesNo
36. Hives, skin rash, hay feverYesNo
37. STI / STD / HPVYesNo
38. HepatitisYesNo
39. HIV / AIDSYesNo
40. Tumor, abnormal growthYesNo
41. Radiation therapyYesNo
42. Chemotherapy, immunosuppressive medicationYesNo
43. Emotional difficultiesYesNo
44. Psychiatric treatmentYesNo
45. Antidepressant medicationYesNo
46. Alcohol / recreational drug useYesNo

ARE YOU:

47. Presently being treated for any other illnessYesNo
48. Aware of a change in your health in the last 24 hours(i.e. fever, chills, new cough, or diarrhea)YesNo
49. Taking medication for weight managementYesNo
50. Taking dietary supplementsYesNo
51. Often exhausted or fatiguedYesNo
52. Experiencing frequent headachesYesNo
53. A smoker, smoked previously or use smokeless tobaccoYesNo
54. Considered a touchy / sensitive personYesNo
55. Often unhappy or depressedYesNo
56. Taking birth control pillsYesNo
57. Currently pregnantYesNo
58. Prostate disordersYesNo

List all medications, 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.

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