top of page
Image by Nappy

(A) Medical History

A. Medical History

Medication Allergies: Do you have drug allergies?
Yes
No
Routine Medication
Yes
No

Problem List/ Past Medical Conditions

Thyroid disease
Anemia
Liver disease
Chronic fatigue
Kidney disease
Diabetes
Asthma/COPD
Stomach
Cancer
Fibromyalgia
Heart Disease
Epilepsy or seizures
Chronic pain
High cholesterol
High blood pressure
Head trauma
Liver problems
Respiratory problems
Intestinal problems
Have you ever had an EKG?
EKG Results

For women only:

Are you currently pregnant or do you think you might be?
Are you planning to get pregnant in the neat future?
bottom of page