Fill in Your Health Information and Submit Date * First Name Last Name Email Gender Identification Age 18-3031-4949+ Date of Birth Have you ever had any of the following? AllergiesLoss of HearingAsthmaLiver DiseaseElevated Liver Enzyme TestHeartAttackHeart MurmurPositive Stress TestHeart Valve AbnormalityAnginaHearth FailureHigh CholesterolHigh Blood PressureArthritis/RheumatismEpilepsyStrokeDiabetesThyroid troubleCancer (including skin cancer) Do you or have you recently had any of the following? Shortness of BreathChest tightnessWheezingHerniaFainting SpellsRecurrent dizzinessFrequent headachesTremorsLoss of coordinationDifficulty ConcentratingNumbness/tingling extremitiesPalpitations (irregular heartbeat)Pain or discomfort in chestHigh cholesterolSwelling of feetLeg pain while walkingPainful varicose veins Do you or have you recently had any of the following? Back trouble/painNeck trouble/painJoint injury/pain/swellingCarpal tunnel syndromeChronic fatigueUndesired/unexplained weight lossDifficulty sleepingLow blood sugar How did you hear about us? BrochurePostcardReferralOther What medications are you currently taking? Have you had any surgeries? Do any diseases run in your family? If so which ones? If you are currently under a doctor's care, please describe below: Do you currently smoke, vape, or use tobacco products? Have you ever smoked? Do you drink alcohol? If so, how much per week? When was your most recent physical? Cholesterol A1C Blood Sugar Blood Pressure How much exercise do you get in a typical week? How would you describe your diet? Any additional notes
