History form

    Medical History Form



    9. Check the conditions that apply to you or any member of your immediate relatives:*

    AsthmaCardiac diseaseHypertensionEpilepsyCancerDiabetesPsychiatric disorderOther

    11. Check the symptoms that you're currently experiencing:*

    Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther

    13. Are you currently taking any medication?*

    YesNo

    15. Do you have any medication allergies?*

    YesNoNot Sure

    19. How often do you consume alcohol?*

    DailyWeeklyMonthlyOccasionallyNever

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