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Patient Information Form

Please complete the form below.
If you have not previously inquired or are not a current patient of ours please our inquiry form before completing the below information. *is required. Please make sure that you have completed all fields. If you receive an error, review your submission for any highlighted areas that may be missing.

**If you have previously completed the form below, you may bypass this step unless you have updated information to share.

First Name

Last Name

ID Code provided

Date of Birth

Current Weight

Height

Sex at birth:

Phone Number

Please select all that apply:

Cardiovascular

HEART ATTACK

CONGESTIVE HEART FAILURE

HIGH CHOLESTEROL

HEART DISEASE

CORONARY ARTERY DISEASE

HIGH BLOOD PRESSURE

LOW BLOOD PRESSURE

ARRHYTHMIAS

NONE

Musculoskeletal

OSTEOARTHRITIS OF THE KNEE

OSTEOARTHRITIS OF THE HIP

OSTEOARTHRITIS - OTHER

OSTEOPENIA

BONE FRACTURE

MUSCLE CRAMPS/SPASMS

OSTEOPOROSIS

LOW BACK PAIN

BUNION

NONE

Neurological

STROKE

MIGRAINES / HEADACHES

FIRBOMYALGIA

CARPAL TUNNEL SYNDROME

INSOMNIA

ALZHEIMER’S DISEASE / DEMENTIA

MULTIPLE SCLEROSIS

NEUROPATHY

NONE

Psychiatric

BIPOLAR DISORDER

SCHIZOPHRENIA

ANXIETY

DEPRESSION

POST-TRAUMATIC STRESS DISORDER

ATTENTION DEFICIT DISORDER

NONE

Respiratory

ASTHMA

BRONCHITIS

COPD

EMPHYSEMA

SLEEP APNEA

VALLEY FEVER

NONE

Head/Ears/Eyes/Nose/Throat

NEARSIGHTEDNESS

FARSIGHTEDNESS

CONCUSSION

HEARING LOSS

TINNITUS

DEVIATED SEPTUM

TONSILLITIS

PERIODONTAL DISEASE

NONE

Gastroenterology

ACID REFLUX

APPENDICITIS

IBS

HERNIA

ULCER

NONE

Hepatic

LIVER CIRRHOSIS

HEPATITIS B

HEPATITIS A

HEPATITIS C

NONE

Hematological

ANEMIA

VITAMIN D DEFICIENCY

NONE

Endocrine

DIABETES TYPE I

DIABETES TYPE II

OBESITY

HYPERTHYROIDISM

HYPOTHYROIDISM

NONE

Urinary

CHRONIC BLADDER INFECTIONS

KIDNEY STONES

RENAL FAILURE

NONE

Dermatological

DERMATITIS

ACNE

PSORIASIS

ECZEMA

NONE

Immune / Allergy

SEASONAL ALLERGIES

GOUT

HIV

LUPUS

RHEUMATOID ARTHRITIS

CANCER

SJOGREN'S SYNDROME

NONE

Reproductive Health:

Contraception

If other, please list brand:

Reproductve (Female)

UTERINE FIBROIDS

ENDOMETRIOSIS

OVARIAN CYSTS

POST-MENOPAUSAL

SEXUALLY TRANSMITTED DISEASES

HYSTERECTOMY

NONE

Reproductve (Male)

PROSTATIC HYPERTROPHY

PROSTATE CANCER

ERECTILE DYSFUNCTION

HYPOGONADISM

SEXUALLY TRANSMITTED DISEASES

VASECTOMY

NONE

Date of last menstration:

Social History:

Smoking History

Marijuana History

Alcohol consumption

How many packs (or cigarettes) do you smoke per day

When was the last time you consumed?

Medications and Surgeries:

Please list the medications and/or dietary supplements you are currently taking.

Please list any surgeries you've had.

If you have your medications digitally written out you may upload it here.

Upload File

Upload supported file (Max 15MB)

Allergies:

Do you have any drug allergies?

Do you have any allergies to Latex, Shellfish, or Iodine?

Do you have any allergies to foods? (Eg: soy, egg, etc)

Please list all items that you are allergic to, and reactions.

Have you had any significant weight loss? If so how much and over what time period?

Is there anything else you would like to share with us?

Please make sure that you have completed all fields. If you receive an error, review your submission for any highlighted areas that may be missing.

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