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Medical History

 

                 
  1. hospitalization for illness or injury
No Yes
  1. an allergic reaction to
  1. heart problems, or cardiac stent within the last six months
No Yes
  1. history of infective endocarditis
No Yes
  1. artificial heart valves, repaired heart defect (PFO)
No Yes
  1. pacemaker or implantable defibrillator
No Yes
  1. orthopedic implant (joint replacement)
No Yes
  1. rheumatic or scarlet fever
No Yes
  1. high or low blood pressure
No Yes
  1. a stroke (taking blood thinners)
No Yes
  1. anemia or other blood disorder
No Yes
  1. prolonged bleeding due to a slight cut (INR>3.5)
No Yes
  1. emphysema, shortness of breath, sarcoidosis
No Yes
  1. tuberculosis, measles, chicken pox
No Yes
  1. asthma
No Yes
  1. breathing or sleep disorders (i.e. sleep apnea, snoring, sinus)
No Yes
  1. kidney disease
No Yes
  1. liver disease
No Yes
  1. jaundice
No Yes
  1. thyroid, parathyroid disease, or calcium deficiency
No Yes
  1. hormone deficiency
No Yes
  1. high cholesterol or taking statin drugs
No Yes
  1. diabetes
No Yes
  1. stomach or duodenal ulcer
No Yes
  1. digestive problems (i.e. celiac disease, gastric reflux)
No Yes
  1. osteoporosis/osteopenia (i.e. taking bisphosphonates)
No Yes
  1. arthritis
No Yes
  1. autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
No Yes
  1. glaucoma
No Yes
  1. contact lenses
No Yes
  1. head or neck injuries
No Yes
  1. epilepsy, convulsions (seizures)
No Yes
  1. neurologic disorders (ADD/ADHD, prion disease)
No Yes
  1. viral infections and cold sores
No Yes
  1. any lumps or swelling in the mouth
No Yes
  1. hives, skin rash, hay fever
No Yes
  1. STI/ STD/ HPV
No Yes
  1. hepatitis
No Yes
  1. HIV/ AIDS
No Yes
  1. tumor, abnormal growth
No Yes
  1. radiation therapy
No Yes
  1. chemotherapy, immunosuppressive medication
No Yes
  1. emotional difficulties
No Yes
  1. psychiatric treatment
No Yes
  1. antidepressant medication
No Yes
  1. alcohol / recreational drug use
No Yes

ARE YOU:

  1. presently being treated for any other illness
No Yes
  1. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
No Yes
  1. taking medication for weight management
No Yes
  1. taking dietary supplements
No Yes
  1. often exhausted of fatigued
No Yes
  1. experiencing frequent headaches
No Yes
  1. a smoker, smoked previously or use smokeless tobacco
No Yes
  1. considered a touchy / sensitive person
No Yes
  1. often unhappy and depressed
No Yes
  1. taking birth control pills
No Yes
  1. currently pregnant
No Yes
  1. prostate disorders
No Yes

 

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.