Medical Health History

Note: This page is optional. However, please be advised that any missing information will be reviewed with your provider during the initial evaluation, which may affect treatment decisions made on evaluation day.

Full Name:

Email:

Patient Medical Health History

Do you have any of the following physical conditions? (Check if applies)

Condition	Check if applies	Explanation (if applicable)
Drug Allergies
Asthma
High Blood Pressure
High Cholesterol
Kidney or Liver Dysfunction
Heart Disease
Cardiac Arrhythmia
Seizures
Glaucoma
Diabetes
Genetic Diseases
Cancer
Chronic Pain
Sleep Disorders
Learning/Developmental Disorders

Reproductive and Hormonal Health

Are you receiving Hormone Replacement Therapy (HRT)?

Yes No

For what reason:

What type of HRT:

Are you pregnant or planning to become pregnant?

Yes No

Other Medical Conditions Not Listed, Please Explain: