Patient Medical History

Do you have a history of or any early findings suggestive of the following?:

Yes     No   Not Sure

  �     �      �     Blood disorders

  �     �      �     Cancer

  �     �      �     Immune Disorders

  �     �      �     Poor Wound Healing

  �     �      �     Edema or excessive fluid retention

  �     �      �     Neurological disorders

  �     �      �     Thyroid, diabetes or other endocrine disorder, including insulin resistance

  �     �      �     Any known nutrition deficiency including minerals and electrolytes

  �     �      �     Hyperlipidemia (high cholesterol)

  �     �      �     Upper respiratory disorders

  �     �      �     Smoker

  �     �      �     Lung Disorder (i.e.asthma, emphysema)

  �     �      �     High Blood Pressure

  �     �      �     Heart Disease including atherosclerosis, angina, heart failure or history of heart attack

  �     �      �     Renal or kidney disease

  �     �      �     Liver disease

  �     �      �     Drug Allergies

  �     �      �     Orthopedic or muscle disorder, including fracture, joint disorder or carpel tunnel syndrome

  �     �      �     Emotional disorders

  �     �      �     Surgery

  �     �      �     Glaucoma

  �     �      �     Chemical Dependency

  �     �      �     Rheumatoid arthritis, lupus, or connective tissue diseases

  �     �      �     Other illness not yet noted

If you answered yes to any of the above questions, please elaborate (i.e. duration of illness, any treatment or surgery

Received, amount smoked and for how long).

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

I have truthfully and to the best of my knowledge answered all the questions on this questionnaire.

Patient Signature: __________________________________________________________ Date: ___________________