Please fill out the following form and submit
List your health concerns in order of importance:
Has anyone in your immediate family ever suffered from the following:
When was your Last (if applicable):
Did you receive a normal series of childhood vaccinations?
Any vaccination reactions or other notes in vaccination history?
Do you currently used, or have you used the following in the past (Check or answer any that apply)
Do you presently smoke or chew tobacco?
Does anyone else smoke in your household?
Do you presently or have you ever used recreational drugs?
Do you currently take any prescription or over the counter medications?
Do you currently take and supplements?
Energy and Weight
Please indicate your energy on a scale of 1-10 (1=Poor, 10=Excellent)
If you are troubled by daytime fatigue, at what time do you experience this?
For the Next Section:
If applicable, please indicate if you currently, or have ever suffered from the following conditions in the past.
Skin and Head
Do you Get Up to Urinate at Night?
Do you perform a testicular self-exam?
Please list any types of hormonal birth control used in the past and how old you were when you used this method:
Anything Else you Think We should Know about?