Name *

First Name

Last Name

Phone *

(###)

###

####

Please check any illness/medical condition you have now or have had in the past:

Arthritis

Blood Disorders

Bowel Problems

Cancer

Chest Pain

Chronic Pain

Diabetes

Glaucoma/Vision Problems

Heart Attack

Hepatitis

Liver Disease

Lung Disease/Breathing Problems

Migraines

Seizures/Epilepsy

Stomach Problems

Stroke

Thyroid Disease

Ulcer

High Blood Pressure*

High Cholesterol**

Are you currently on any medication for high blood pressure? *

Yes

No

Are you currently on any medication for high cholesterol? *

Yes

No

Date of your most recent lab work:

MM

DD

YYYY

Have you ever had an EKG? *

Yes

No

Was the EKG:

Normal

Abnormal

Unknown

Have you ever discontinued or altered the prescribed dose of your medication without the recommendation of your treating physician? *

Yes

No