Medical History Form

Please complete the form below, prior to your appointment. Don’t forget to click “Submit” at the end of the form. No need to print anything once you click submit.

Intake Form

Step 1 of 22

Today's Date

Please select which state you are interested in?(Required)

First Name(Required)

First

Last Name(Required)

Last

Cell Phone or Main Phone(Required)

Email(Required)

Consent(Required)

I hereby authorize Physicians Research Group to input all personal and medical information below into their database. I understand that this information will only be used by Physicians Research Group and not shared with a third party without my express permission. You may be contacted by a staff member at a research study site if you meet the study requirements to discuss participation in the study. By providing your phone number and/or email to us, you consent to being contacted by us (including text messages).

I agree to the privacy policy.

Consent(Required)

I understand that there is an inherent risk of COVID-19 exposure when visiting any medical facility or research site.

I agree to the COVID-19 policy.

A. GENERAL INFORMATION

Address

Street Address City State ZIP Code

Date of Birth(Required)

Age

Gender(Required)

Marital Status

Height

Weight

Current Employment Status

Work Phone

Highest Level of Education

Race

More than one race; specify:

Ethnicity

Emergency Contact

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Relationship

Address of Emergency Contact

Same as previous

Street Address City State ZIP Code

Consent

I give my permission for Physicians Research Group to contact this person in case of an emergency.

B. PRIMARY / FAMILY PHYSICIAN

Primary Care / Family Physician Name

Address of Primary Care / Family Physician

Street Address City State ZIP Code

Office Phone

Office Fax

Date of last visit?

Consent

I give my permission for Physicians Research Group to notify my primary care physician of my study participation.

Have you ever participated in a research study before?

Yes

If Yes, Date and Indidication?

C. MEDICATIONS

Include all prescriptions, over-the-counter medications, and vitamins that you are taking.

Medication Name

Date Started

Dosage

Times Taken Per Day

Reason For Taking Medication

D. MEDICAL HISTORY

Check boxes of all current and/or diagnosed medical conditions you have.

Immunological Conditions

AIDS/HIV

Allergies

Autoimmune Disease (RA, Lupus, etc.)

Rheumatic Fever

Other

AIDS/HIV

Date of Diagnosis or Onset of AIDS/HIV

Month

Day

Year

Is AIDS/HIV Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for AIDs/HIV?

Yes

End Date of Diagnosis/Onset of AIDS/HIV

Month

Day

Year

Rheumatic Fever

Date of Diagnosis or Onset of Rheumatic Fever

Month

Day

Year

Is Rheumatic Fever Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Rheumatic Fever?

Yes

End Date of Diagnosis/Onset of Rheumatic Fever

Month

Day

Year

Allergies

Date of Diagnosis or Onset of Allergies

Month

Day

Year

Are Allergies Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Allergies?

Yes

End Date of Diagnosis/Onset of Allergies

Month

Day

Year

Autoimmune Disease

Date of Diagnosis or Onset of Autoimmune Disease

Month

Day

Year

Is Autoimmune Disease Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Autoimmune Disease?

Yes

End Date of Diagnosis/Onset of Autoimmune Disease

Month

Day

Year

"Other" Immunological Condition

Please describe "Other" Immunological Condition:

Date of Diagnosis or Onset of "Other" Immunological Condition

Month

Day

Year

Is "Other" Immunological Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for "Other" Immunological Condition?

Yes

End Date of Diagnosis/Onset of "Other" Immunological Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Cardiovascular Conditions

Angina (Chest Pain)

Bleeding Problems

Blood Clots

Bypass Surgery

Congestive Heart Failure (CHF)

Fainting and/or blackouts

Heart Attack

High Blood Pressure

High Cholesterol

Irregular/rapid heartbeat

Low Blood Pressure

Pacemaker

Peripheral Artery Disease (PAD)

Shortness of Breath

Stent Placement

Stroke or TIA

Other

Angina (Chest Pain)

Date of Diagnosis or Onset of Angina

Month

Day

Year

Is Angina Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Angina?

Yes

End Date of Diagnosis/Onset of Angina

Month

Day

Year

Congestive Heart Failure

Date of Diagnosis or Onset of Congestive Heart Failure

Month

Day

Year

Is CHF Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications related to CHF?

Yes

End Date of Diagnosis/Onset of CHF

Month

Day

Year

High Blood Pressure

Date of Diagnosis or Onset of High Blood Pressure

Month

Day

Year

Is High Blood Pressure Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for High Blood Pressure?

Yes

End Date of Diagnosis/Onset of High Blood Pressure

Month

Day

Year

Shortness of Breath

Date of Diagnosis or Onset of Shortness of Breath

Month

Day

Year

Is Shortness of Breath Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Shortness of Breath?

Yes

End Date of Diagnosis/Onset of Shortness of Breath

Month

Day

Year

Low Blood Pressure

Date of Diagnosis or Onset of Low Blood Pressure

Month

Day

Year

Is Low Blood Pressure Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Low Blood Pressure?

Yes

End Date of Diagnosis/Onset of Low Blood Pressure

Month

Day

Year

High Cholesterol

Date of Diagnosis or Onset of High Cholesterol

Month

Day

Year

Is High Cholesterol Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for High Cholesterol?

Yes

End Date of Diagnosis/Onset of High Cholesterol

Month

Day

Year

Stroke or TIA

Date of Diagnosis or Onset of Stroke or TIA

Month

Day

Year

Is TIA Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for TIA?

Yes

End Date of Diagnosis/Onset of TIA

Month

Day

Year

Blood Clots

Date of Diagnosis or Onset of Blood Clots

Month

Day

Year

Are Blood Clots Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Blood Clots?

Yes

End Date of Diagnosis/Onset of Blood Clots

Month

Day

Year

Bleeding Problems

Date of Diagnosis or Onset of Bleeding Problems

Month

Day

Year

Are Bleeding Problems Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Bleeding Problems?

Yes

End Date of Diagnosis/Onset of Bleeding Problems

Month

Day

Year

Heart Attack

Date of Diagnosis or Onset of Heart Attack

Month

Day

Year

Is Heart Attack Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Heart Attack?

Yes

End Date of Diagnosis/Onset of Heart Attack

Month

Day

Year

Stent Placement

Date of Stent Placement

Month

Day

Year

Are you taking any medications for Stent Placement?

Yes

Bypass Surgery

Date of Bypass Surgery

Month

Day

Year

Are you taking any medications for Bypass Surgery?

Yes

PAD

Date of Diagnosis or Onset of PAD

Month

Day

Year

Is PAD Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for PAD?

Yes

End Date of Diagnosis/Onset of PAD

Month

Day

Year

Pacemaker Implantation

Date of Pacemaker Implantation

Month

Day

Year

Are you taking any medications related to Pacemaker?

Yes

Irregular Heartbeat

Date of Diagnosis or Onset of Irregular Heartbeat

Month

Day

Year

Is Irregular Heartbeat Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Irregular Heartbeat?

Yes

End Date of Diagnosis/Onset of Irregular Heartbeat

Month

Day

Year

Fainting Spells

Date of Diagnosis or Onset of Fainting Spells

Month

Day

Year

Is Fainting Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Fainting?

Yes

End Date of Diagnosis/Onset of Fainting

Month

Day

Year

Other" Cardiovascular Ongoing Medical Condition

Please describe Other:

Date of Diagnosis or Onset of Other Cardiovascular Condition

Month

Day

Year

Is "Other" Cardiovascular Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for "Other" Cardiovascular condition?

Yes

End Date of Diagnosis/Onset of Other Cardiovascular Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Dermatological Conditions

Skin Cancer Type/Location:

Actinic Keratosis (Precancerous Skin Growth)

Atopic Dermatitis (Eczema)

Psoriasis/Plaque Psoriasis

Scarring Acne

Hidradenitis Suppurativa (HS)

Rosacea

Shingles

Diabetic Foot Ulcer (R/L/BL)

Pressure Ulcer

Rash

Other

Skin Cancer

Please describe skin cancer type and location:

Date of Diagnosis or Onset of Skin Cancer

Month

Day

Year

Is Skin Cancer Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Skin Cancer?

Yes

End Date of Diagnosis/Onset of Skin Cancer

Month

Day

Year

AK

Date of Diagnosis or Onset of AK

Month

Day

Year

Is AK Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for AK?

Yes

End Date of Diagnosis/Onset of AK

Month

Day

Year

Eczema

Date of Diagnosis or Onset of Eczema

Month

Day

Year

Is Eczema Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Eczema?

Yes

End Date of Diagnosis/Onset of Eczema

Month

Day

Year

Psoriasis

Date of Diagnosis or Onset of Psoriasis

Month

Day

Year

Is Psoriasis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Psoriasis?

Yes

End Date of Diagnosis/Onset of Psoriasis

Month

Day

Year

Scarring Acne

Date of Diagnosis or Onset of Scarring Acne

Month

Day

Year

Is Scarring Acne Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Scarring Acne?

Yes

End Date of Diagnosis/Onset of Scarring Acne

Month

Day

Year

HS

Date of Diagnosis or Onset of HS

Month

Day

Year

Is HS Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for HS?

Yes

End Date of Diagnosis/Onset of HS

Month

Day

Year

Rosacea

Date of Diagnosis or Onset of Rosacea

Month

Day

Year

Is Rosacea Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Rosacea?

Yes

End Date of Diagnosis/Onset of Rosacea

Month

Day

Year

Shingles

Date of Diagnosis or Onset of Shingles

Month

Day

Year

Is Shingles Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Shingles?

Yes

End Date of Diagnosis/Onset of Shingles

Month

Day

Year

Diabetic Foot Ulcer

Is or was your diabetic foot ulcer on your:

Right foot

Left foot

Both feet

Date of Diagnosis or Onset of Ulcer(s)

Month

Day

Year

Is Diabetic Foot Ulcer Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Diabetic Foot Ulcer?

Yes

End Date of Diagnosis/Onset of Diabetic Foot Ulcer

Month

Day

Year

Pressure Ulcer(s)

Date of Diagnosis or Onset of Pressure Ulcer(s)

Month

Day

Year

Is Pressure Ulcer Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Pressure Ulcer?

Yes

End Date of Diagnosis/Onset of Pressure Ulcer

Month

Day

Year

Rash

Date of Diagnosis or Onset of Rash

Month

Day

Year

Is Rash Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Rash?

Yes

End Date of Diagnosis/Onset of Rash

Month

Day

Year

Other Dermatological Conditions

Please describe Other Dermatological Conditions:

Date of Diagnosis or Onset of "Other" Dermatological Conditions

Month

Day

Year

Is "Other" Dermatological Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for "Other" Dermatological Conditions?

Yes

End Date of Diagnosis/Onset of "Other" Dermatological Conditions

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Ears, Nose and Throat Conditions

Allergies/Sinusitis

Hearing Loss

Ear Pain or Itch

Dizziness

Nasal Congestion

Hoarseness

Sinus Pressure or Pain

Snoring or Apnea

Throat Pain

Other

Allergies/Sinusitis

Date of Diagnosis or Onset of Allergies/Sinusitis

Month

Day

Year

Are Allergies/Sinusitis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Allergies/Sinusitis?

Yes

End Date of Diagnosis/Onset of Allergies/Sinusitis

Month

Day

Year

Hearing Loss

Date of Diagnosis or Onset of Hearing Loss

Month

Day

Year

Is Hearing Loss Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Hearing Loss?

Yes

End Date of Diagnosis/Onset of Hearing Loss

Month

Day

Year

Ear Pain

Date of Diagnosis or Onset of Ear Pain

Month

Day

Year

Is Ear Pain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Ear Pain?

Yes

End Date of Diagnosis/Onset of Ear Pain

Month

Day

Year

Dizziness

Date of Diagnosis or Onset of Dizziness

Month

Day

Year

Is Dizziness Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Dizziness?

Yes

End Date of Diagnosis/Onset of Dizziness

Month

Day

Year

Nasal Congestion

Date of Diagnosis or Onset of Nasal Congestion

Month

Day

Year

Is Nasal Congestion Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Nasal Congestion?

Yes

End Date of Diagnosis/Onset of Nasal Congestion

Month

Day

Year

Hoarseness

Date of Diagnosis or Onset of Hoarseness

Month

Day

Year

Is Hoarseness Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Hoarseness?

Yes

End Date of Diagnosis/Onset of Hoarseness

Month

Day

Year

Sinus Pressure

Date of Diagnosis or Onset of Sinus Pressure

Month

Day

Year

Is Sinus Pressure Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Sinus Pressure?

Yes

End Date of Diagnosis/Onset of Sinus Pressure

Month

Day

Year

Snoring/Apnea

Date of Diagnosis or Onset of Snoring/Apnea

Month

Day

Year

Is Snoring/Apnea Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Snoring/Apnea?

Yes

End Date of Diagnosis/Onset of Snoring/Apnea

Month

Day

Year

Throat Pain

Date of Diagnosis or Onset of Throat Pain

Month

Day

Year

Is Throat Pain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Throat Pain?

Yes

End Date of Diagnosis/Onset of Throat Pain

Month

Day

Year

Other ENT Condition

Please describe "Other" ENT Conditions:

Date of Diagnosis or Onset of "Other" ENT Condition

Month

Day

Year

Is "Other" ENT Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for "Other" ENT Condition?

Yes

End Date of Diagnosis/Onset of "Other" ENT Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Genitourinary Conditions

Urinary Frequency

Burning with Urination

Blood in Urine

Problems Urinating

Problems with Sex (ED/Menopause)

Sexually Transmitted Infection (STI)

Benign Prostatic Hyperplasia (BPH)

Kidney Stones

Kidney Problems

Other

Urinary Frequency

Date of Diagnosis or Onset of Urinary Frequency

Month

Day

Year

Is Urinary Frequency Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Urinary Frequency?

Yes

End Date of Diagnosis/Onset of Urinary Frequency

Month

Day

Year

Burning with Urination

Date of Diagnosis or Onset of Burning with Urination

Month

Day

Year

Is Burning with Urination Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Burning with Urination?

Yes

End Date of Diagnosis/Onset of Burning with Urination

Month

Day

Year

Blood in Urine

Date of Diagnosis or Onset of Blood in Urine

Month

Day

Year

Is Blood in Urine Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Blood in Urine?

Yes

End Date of Diagnosis/Onset of Blood in Urine

Month

Day

Year

Problems Urinating

Date of Diagnosis or Onset of Problems Urinating

Month

Day

Year

Is Problems Urinating Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Problems Urinating?

Yes

End Date of Diagnosis/Onset of Problems Urinating

Month

Day

Year

Problems with Sex

Date of Diagnosis or Onset of Problems with Sex

Month

Day

Year

Are Problems with Sex Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Problems with Sex?

Yes

End Date of Diagnosis/Onset of Problems with Sex

Month

Day

Year

Sexually Transmitted Infection

Type of sexually transmitted infection, if known:

Date of Diagnosis or Onset of Sexually Transmitted Infection

Month

Day

Year

Are Sexually Transmitted Infection Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Sexually Transmitted Infection?

Yes

End Date of Diagnosis/Onset of Sexually Transmitted Infection

Month

Day

Year

BPH

Date of Diagnosis or Onset of BPH

Month

Day

Year

Is BPH Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for BPH?

Yes

End Date of Diagnosis/Onset of BPH

Month

Day

Year

Kidney Stone

Date of Diagnosis or Onset of Kidney Stone

Month

Day

Year

Are Kidney Stones Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Kidney Stones?

Yes

End Date of Diagnosis/Onset of Kidney Stones

Month

Day

Year

Kidney Problems

Date of Diagnosis or Onset of Kidney Problems

Month

Day

Year

Are Kidney Problems Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Kidney Problems?

Yes

End Date of Diagnosis/Onset of Kidney Problems

Month

Day

Year

Other Genitourinary Condition

Please describe "Other" Genitourinary Condition:

Date of Diagnosis or Onset of "Other" Genitourinary Conditions

Month

Day

Year

Is "Other" Genitourinary Conditions Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for "Other" Genitourinary Conditions?

Yes

End Date of Diagnosis/Onset of "Other" Genitourinary Conditions

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Gastrointestinal Conditions

Nausea

GERD (Reflux/Heartburn)

Vomiting (Single Episode/Constant)

Constipation (Intermittent/Chronic)

Abdominal Pain (Intermittent)

Diarrhea (Intermittent)

Blood in Stool

Lactose intolerance

Diverticulitis

Crohn’s Disease/Ulcerative Colitis

Gallstones

Hernia

Gastric Bypass Surgery

Gastric/Peptic Ulcer(s)

Irritable Bowel Syndrome (IBS)

Celiac Disease

Hepatitis (Infection type if known)

Other

Nausea

Date of Diagnosis or Onset of Nausea

Month

Day

Year

Is Nausea Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Nausea?

Yes

End Date of Diagnosis/Onset of Nausea

Month

Day

Year

GERD

Date of Diagnosis or Onset of GERD

Month

Day

Year

Is GERD Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for GERD?

Yes

End Date of Diagnosis/Onset of GERD

Month

Day

Year

Vomiting

Vomiting (Single Episode/Constant)

Single Episode

Constant

Date of Diagnosis or Onset of Vomiting

Month

Day

Year

Is Vomiting Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Vomiting?

Yes

End Date of Diagnosis/Onset of Vomiting

Month

Day

Year

Constipation

Constipation (Intermittent/Chronic)

Intermittent

Chronic

Date of Diagnosis or Onset of Constipation

Month

Day

Year

Is Constipation Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Constipation?

Yes

End Date of Diagnosis/Onset of Constipation

Month

Day

Year

Abdominal Pain

Date of Diagnosis or Onset of Abdominal Pain

Month

Day

Year

Is Abdominal Pain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Abdominal Pain?

Yes

End Date of Diagnosis/Onset of Abdominal Pain

Month

Day

Year

Diarrhea

Date of Diagnosis or Onset of Diarrhea

Month

Day

Year

Is Diarrhea Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Diarrhea?

Yes

End Date of Diagnosis/Onset of Diarrhea

Month

Day

Year

Blood in Stool

Date of Diagnosis or Onset of Blood in Stool

Month

Day

Year

Is Blood in Stool Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Blood in Stool?

Yes

End Date of Diagnosis/Onset of Blood in Stool

Month

Day

Year

Lactose Intolerance

Date of Diagnosis or Onset of Lactose Intolerance

Month

Day

Year

Is Lactose Intolerance Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Lactose Intolerance?

Yes

End Date of Diagnosis/Onset of Lactose Intolerance

Month

Day

Year

Diverticulosis

Date of Diagnosis or Onset of Diverticulosis

Month

Day

Year

Is Diverticulitis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Diverticulitis?

Yes

End Date of Diagnosis/Onset of Diverticulitis

Month

Day

Year

Crohn's Disease

Date of Diagnosis or Onset of Crohn's Disease

Month

Day

Year

Is Crohn's Disease Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Crohn's Disease?

Yes

End Date of Diagnosis/Onset of Crohn's Disease

Month

Day

Year

Gallstones

Date of Diagnosis or Onset of Gallstones

Month

Day

Year

Is Gallstones Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Gallstones?

Yes

End Date of Diagnosis/Onset of Gallstones

Month

Day

Year

Hernia

Date of Diagnosis or Onset of Hernia

Month

Day

Year

Is Hernia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Hernia?

Yes

End Date of Diagnosis/Onset of Hernia

Month

Day

Year

Gastric Bypass Surgery

Date of Gastric Bypass Surgery

Month

Day

Year

Is Gastric Bypass Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Gastric Bypass Surgery?

Yes

End Date of Diagnosis/Onset of Gastric Bypass

Month

Day

Year

Gastric / Peptic Ulcers

Date of Diagnosis or Onset of Ulcers

Month

Day

Year

Are Ulcers Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Ulcers?

Yes

End Date of Diagnosis/Onset of Ulcers

Month

Day

Year

Irritable Bowel Syndrome (IBS)

Date of Diagnosis or Onset of Irritable Bowel Syndrome (IBS)

Month

Day

Year

Is Irritable Bowel Syndrome (IBS) Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Irritable Bowel Syndrome (IBS)?

Yes

End Date of Diagnosis/Onset of Irritable Bowel Syndrome (IBS)

Month

Day

Year

Celiac Disease

Date of Diagnosis or Onset of Celiac Disease

Month

Day

Year

Is Celiac Disease Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Celiac Disease?

Yes

End Date of Diagnosis/Onset of Celiac Disease

Month

Day

Year

Hepatitis

Hepatitis – Infection type if known:

Date of Diagnosis or Onset of Hepatitis

Month

Day

Year

Is Hepatitis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Hepatitis?

Yes

End Date of Diagnosis/Onset of Hepatitis

Month

Day

Year

Other Gastrointestinal Condition

Please describe "Other" Gastrointestinal Condition:

Date of Diagnosis or Onset of "Other" Gastrointestinal Condition

Month

Day

Year

Is "Other" Gastrointestinal Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for "Other" Gastrointestinal Condition?

Yes

End Date of Diagnosis/Onset of "Other" Gastrointestinal Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Metabolic/Endocrine Conditions

Hyperthyroidism

Hypothyroidism

Fatigue

Heat Intolerance

Cold Intolerance

Uncontrolled Weight Gain

Uncontrolled Weight Loss

Diabetes Type II

Diabetes Type I

Other

Date of Diagnosis or Onset of Hyperthyroidism

Month

Day

Year

Date of Diagnosis or Onset of Hypothyroidism

Month

Day

Year

Date of Diagnosis or Onset of Fatigue

Month

Day

Year

Date of Diagnosis or Onset of Heat Intolerance

Month

Day

Year

Date of Diagnosis or Onset of Cold Intolerance

Month

Day

Year

Date of Diagnosis or Onset of Uncontrolled Weight Gain

Month

Day

Year

Date of Diagnosis or Onset of Uncontrolled Weight Loss

Month

Day

Year

Date of Diagnosis or Onset of Diabetes Type II

Month

Day

Year

Date of Diagnosis or Onset of Diabetes Type I

Month

Day

Year

Please Describe "Other" Metabolic/Endocrine Condition:

Date of Diagnosis or Onset of "Other" Metabolic/Endocrine Condition

Month

Day

Year

Is Hyperthyroidism Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Hypothyroidism Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Fatigue Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Heat Intolerance Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Cold Intolerance Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Uncontrolled Weight Gain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Uncontrolled Weight Loss Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Diabetes Type II Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Diabetes Type I Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is "Other" Metabolic/Endocrine Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Hyperthyroidism?

Yes

Are you taking any medications for Hypothyroidism?

Yes

Are you taking any medications for Fatigue?

Yes

Are you taking any medications for Heat Intolerance?

Yes

Are you taking any medications for Cold Intolerance?

Yes

Are you taking any medications for Uncontrolled Weight Gain?

Yes

Are you taking any medications for Uncontrolled Weight Loss?

Yes

Are you taking any medications for Diabetes Type II?

Yes

Are you taking any medications for Diabetes Type I?

Yes

Are you taking any medications for "Other" Metabolic/Endocrine Condition?

Yes

End Date of Diagnosis/Onset of Hyperthroidism

Month

Day

Year

End Date of Diagnosis/Onset of Hypothroidism

Month

Day

Year

End Date of Diagnosis/Onset of Fatigue

Month

Day

Year

End Date of Diagnosis/Onset of Heat Intolerance

Month

Day

Year

End Date of Diagnosis/Onset of Cold Intolerance

Month

Day

Year

End Date of Diagnosis/Onset of Uncontrolled Weight Gain

Month

Day

Year

End Date of Diagnosis/Onset of Uncontrolled Weight Loss

Month

Day

Year

End Date of Diagnosis/Onset of Diabetes Type II

Month

Day

Year

End Date of Diagnosis/Onset of Diabetes Type I

Month

Day

Year

End Date of Diagnosis/Onset of "Other" Metabolic/Endocrine Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Musculoskeletal Conditions

Chronic Regional Pain Syndrome (CRPS)

Fibromyalgia

Rheumatoid Arthritis

Osteoarthritis

Gout

Chronic Low Back Pain

Joint Pain (Hips, Knees, elbows, shoulders etc.)

Neck Pain

Muscle Pains

Artificial/Replacement Knee

Artificial/Replacement Hip

Joint swelling (Hips, Knees, elbows, shoulders etc.)

Other

Date of Diagnosis or Onset of CRPS

Month

Day

Year

Date of Diagnosis or Onset of Fibromyalgia

Month

Day

Year

Date of Diagnosis or Onset of Rheumatoid Arthritis

Month

Day

Year

Date of Diagnosis or Onset of Osteoarthritis

Month

Day

Year

Date of Diagnosis or Onset of Gout

Month

Day

Year

Date of Diagnosis or Onset of Chronic Low Back Pain

Month

Day

Year

Date of Diagnosis or Onset of Joint Pain

Month

Day

Year

Date of Diagnosis or Onset of Neck Pain

Month

Day

Year

Date of Diagnosis or Onset of Muscle Pain

Month

Day

Year

Date of Artificial Knee Replacement

Month

Day

Year

Date of Artificial Hip Replacement

Month

Day

Year

Date of Diagnosis or Onset of Joint Swelling

Month

Day

Year

Please describe "Other" Musculoskeletal Condition:

Date of Diagnosis or Onset of "Other" Musculoskeletal Condition

Month

Day

Year

Is CRPS Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Fibromyalgia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Rheumatoid Arthritis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Osteoarthritis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Gout Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Chronic Low Back Pain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Joint Pain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Neck Pain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are Muscle Pains Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Artificial Knee Replacement Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Artificial Hip Replacement Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Joint Swelling Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is "Other" Musculoskeletal Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for CRPS?

Yes

Are you taking any medications for Fibromyalgia?

Yes

Are you taking any medications for Rheumatoid Arthritis?

Yes

Are you taking any medications for Osteoarthritis?

Yes

Are you taking any medications for Gout?

Yes

Are you taking any medications for Chronic Low Back Pain?

Yes

Are you taking any medications for Joint Pain?

Yes

Are you taking any medications for Neck Pain?

Yes

Are you taking any medications for Muscle Pains?

Yes

Are you taking any medications for Artificial Knee Replacement?

Yes

Are you taking any medications for Artificial Hip Replacement?

Yes

Are you taking any medications for Joint Swelling?

Yes

Are you taking any medications for "Other" Musculoskeletal Condition?

Yes

End Date of Diagnosis/Onset of CRPS

Month

Day

Year

End Date of Diagnosis/Onset of Fibromyalgia

Month

Day

Year

End Date of Diagnosis/Onset of Rheumatoid Arthritis

Month

Day

Year

End Date of Diagnosis/Onset of Osteoarthritis

Month

Day

Year

End Date of Diagnosis/Onset of Gout

Month

Day

Year

End Date of Diagnosis/Onset of Chronic Low Back Pain

Month

Day

Year

End Date of Diagnosis/Onset of Joint Pain

Month

Day

Year

End Date of Diagnosis/Onset of Neck Pain

Month

Day

Year

End Date of Diagnosis/Onset of Muscle Pains

Month

Day

Year

End Date of Diagnosis/Onset of Artificial Knee Replacement

Month

Day

Year

End Date of Diagnosis/Onset of Artificial Hip Replacement

Month

Day

Year

End Date of Diagnosis/Onset of Joint Swelling

Month

Day

Year

End Date of Diagnosis/Onset of "Other" Musculoskeletal Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Respiratory Conditions

Asthma

Chronic Bronchitis

COPD

Cough

COVID-19

Cystic Fibrosis

Mesothelioma

Pneumonia (Past/Present/Current)

Tuberculosis (Positive Test)

Other

Date of Diagnosis or Onset of Asthma

Month

Day

Year

Date of Diagnosis or Onset of COVID-19

Month

Day

Year

Pneumonia (Past/Present/Current)

Past

Present

Current

Date of Diagnosis or Onset of Pneumonia

Month

Day

Year

Date of Diagnosis or Onset of Tuberculosis

Month

Day

Year

Date of Diagnosis or Onset of COPD

Month

Day

Year

Date of Diagnosis or Onset of Chronic Bronchitis

Month

Day

Year

Date of Diagnosis or Onset of Cystic Fibrosis

Month

Day

Year

Date of Diagnosis or Onset of Mesothelioma

Month

Day

Year

Date of Diagnosis or Onset of Cough

Month

Day

Year

Please describe "Other" Respiratory Conditions:

Date of Diagnosis or Onset of "Other" Respiratory Conditions

Month

Day

Year

Is Asthma Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Pneumonia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is COVID-19 Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Tuberculosis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is COPD Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Chronic Bronchitis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Cystic Fibrosis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Mesothelioma Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Cough Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is "Other" Respiratory Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Asthma?

Yes

Are you taking any medications for Pneumonia?

Yes

Are you taking any medications for Tuberculosis?

Yes

Are you taking any medications for COVID-19?

Yes

Are you taking any medications for COPD?

Yes

Are you taking any medications for Chronic Bronchitis?

Yes

Are you taking any medications for Cystic Fibrosis?

Yes

Are you taking any medications for Mesothelioma?

Yes

Are you taking any medications for Sleep Apnea?

Yes

Are you taking any medications for Cough?

Yes

Are you taking any medications for "Other" Respiratory Conditions?

Yes

End Date of Diagnosis/Onset of Asthma

Month

Day

Year

End Date of Diagnosis/Onset of Pneumonia

Month

Day

Year

End Date of Diagnosis/Onset of Tuberculosis

Month

Day

Year

End Date of Diagnosis/Onset of COVID-19

Month

Day

Year

End Date of Diagnosis/Onset of COPD

Month

Day

Year

End Date of Diagnosis/Onset of Chronic Bronchitis

Month

Day

Year

End Date of Diagnosis/Onset of Cystic Fibrosis

Month

Day

Year

End Date of Diagnosis/Onset of Mesothelioma

Month

Day

Year

End Date of Diagnosis/Onset of Cough

Month

Day

Year

End Date of Diagnosis/Onset of "Other" Respiratory Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Neurological Conditions

Numbness/Tingling in Extremities

Intermittent Headaches

Migraines (Number per Month: _____)

Muscle weakness (Generalized/Intermittent/Exertion)

Epilepsy

Seizures (Type if known)

Lightheadedness/Dizziness (Intermittent/Constant)

Fainting

Stroke in Brain

Dementia

Alzheimer’s Disease

Muscular Dystrophy

Multiple Sclerosis

Parkinson’s Disease

Post-herpetic Neuralgia (Pain after Shingles)

Other

Seizures (Type if known)

Date of Diagnosis or Onset of Numbness/Tingling in Extremities

Month

Day

Year

Date of Diagnosis or Onset of Intermittent Headaches

Month

Day

Year

Migraines (Number per Month)

Date of Diagnosis or Onset of Migraines

Month

Day

Year

Muscle weakness (Generalized/Intermittent/Exertion)

Generalized

Intermittent

Exertion

Date of Diagnosis or Onset of Muscle Weakness

Month

Day

Year

Date of Diagnosis or Onset of Epilepsy

Month

Day

Year

Date of Diagnosis or Onset of Seizures

Month

Day

Year

Lightheadedness/Dizziness (Intermittent/Constant)

Intermittent

Constant

Date of Diagnosis or Onset of Lightheadedness/Dizziness

Month

Day

Year

Date of Diagnosis or Onset of Fainting

Month

Day

Year

Date of Diagnosis or Onset of Stroke in Brain

Month

Day

Year

Date of Diagnosis or Onset of Dementia

Month

Day

Year

Date of Diagnosis or Onset of Alzheimer's Disease

Month

Day

Year

Date of Diagnosis or Onset of Muscular Dystrophy

Month

Day

Year

Date of Diagnosis or Onset of Multiple Sclerosis

Month

Day

Year

Date of Diagnosis or Onset of Parkinson's Disease

Month

Day

Year

Date of Diagnosis or Onset of Post-Herpetic Neuralgia

Month

Day

Year

Please describe "Other" Neurological Condition:

Date of Diagnosis or Onset of "Other" Neurological Condition

Month

Day

Year

Is Numbness/Tingling in Extremities Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Intermittent Headaches Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are Migraines Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Muscle Weakness Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Epilepsy Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are Seizures Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Lightheadedness/Dizziness Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Fainting Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Stroke in Brain Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Dementia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Alzheimer's Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Muscular Dystrophy Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Multiple Sclerosis Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Parkinson's Disease Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Post-Herpetic Neuralgia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is "Other" Neurological Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Numbness/Tingling in Extremities?

Yes

Are you taking any medications for Intermittent Headaches?

Yes

Are you taking any medications for Migraines?

Yes

Are you taking any medications for Muscle Weakness?

Yes

Are you taking any medications for Epilepsy?

Yes

Are you taking any medications for Seizures?

Yes

Are you taking any medications for Lightheadedness/Dizziness?

Yes

Are you taking any medications for Fainting?

Yes

Are you taking any medications for Stoke in Brain?

Yes

Are you taking any medications for Dementia?

Yes

Are you taking any medications for Alzheimer's?

Yes

Are you taking any medications for Muscular Dystrophy?

Yes

Are you taking any medications for Multiple Sclerosis?

Yes

Are you taking any medications for Parkinson's Disease?

Yes

Are you taking any medications for Post-Herpetic Neuralgia?

Yes

Are you taking any medications for "Other" Neurological Condition?

Yes

End Date of Diagnosis/Onset of Numbness/Tingling in Extremities

Month

Day

Year

End Date of Diagnosis/Onset of Intermittent Headaches

Month

Day

Year

End Date of Diagnosis/Onset of Migraines

Month

Day

Year

End Date of Diagnosis/Onset of Muscle Weakness

Month

Day

Year

End Date of Diagnosis/Onset of Epilepsy

Month

Day

Year

End Date of Diagnosis/Onset of Seizures

Month

Day

Year

End Date of Diagnosis/Onset of Lightheadedness/Dizziness

Month

Day

Year

End Date of Diagnosis/Onset of Fainting

Month

Day

Year

End Date of Diagnosis/Onset of Stroke in Brain

Month

Day

Year

End Date of Diagnosis/Onset of Dementia

Month

Day

Year

End Date of Diagnosis/Onset of Alzheimer's

Month

Day

Year

End Date of Diagnosis/Onset of Muscular Dystrophy

Month

Day

Year

End Date of Diagnosis/Onset of Multiple Sclerosis

Month

Day

Year

End Date of Diagnosis/Onset of Parkinson's Disease

Month

Day

Year

End Date of Diagnosis/Onset of Post-Herpetic Neuralgia

Month

Day

Year

End Date of Diagnosis/Onset of "Other" Neurological Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Hematological/Lymphatic Conditions

Coagulation Disorder

Anemia

Lymphoma (CA*)

Leukemia (CA*)

Myeloma (CA*)

Easy Bruising

Easy Bleeding (hemophilia)

Other

(CA*) Cancer

Type of Cancer

Location of Cancer

Date of Diagnosis or Onset of Coagulation Disorder

Month

Day

Year

Date of Diagnosis or Onset of Anemia

Month

Day

Year

Date of Diagnosis or Onset of Lymphoma

Month

Day

Year

Date of Diagnosis or Onset of Leukemia

Month

Day

Year

Date of Diagnosis or Onset of Myeloma

Month

Day

Year

Date of Diagnosis or Onset of Easy Bruising

Month

Day

Year

Date of Diagnosis or Onset of Hemophilia

Month

Day

Year

Please describe "Other" Hematological/Lymphatic Condition:

Date of Diagnosis or Onset of "Other" Hematological/Lymphatic Condition

Month

Day

Year

Is Coagulation Disorder Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Anemia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Lymphoma Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Leukemia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Myeloma Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Easy Bruising Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is Hemophilia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Is "Other" Hematological/Lymphatic Condition Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Coagulation Disorder?

Yes

Are you taking any medications for Anemia?

Yes

Are you taking any medications for Lymphoma?

Yes

Are you taking any medications for Leukemia?

Yes

Are you taking any medications for Myeloma?

Yes

Are you taking any medications for Easy Bruising?

Yes

Are you taking any medications for Hemophilia?

Yes

Are you taking any medications for "Other" Hematological/Lymphatic Condition

Yes

End Date of Diagnosis/Onset of Coagulation Disorder

Month

Day

Year

End Date of Diagnosis/Onset of Amenia

Month

Day

Year

End Date of Diagnosis/Onset of Lymphoma

Month

Day

Year

End Date of Diagnosis/Onset of Leukemia

Month

Day

Year

End Date of Diagnosis/Onset of Myeloma

Month

Day

Year

End Date of Diagnosis/Onset of Easy Bruising

Month

Day

Year

End Date of Diagnosis/Onset of Hemophilia

Month

Day

Year

End Date of Diagnosis/Onset of "Other" Hematological/Lymphatic Condition

Month

Day

Year

D. MEDICAL HISTORY (Continued)

Check boxes of all current and/or diagnosed medical conditions you have.

Mental Health Conditions

Anxiety

Depression

Illicit Drug Use

Insomnia

Major Depressive Disorder (MDD)

Obsessive–Compulsive Disorder (OCD)

Postpartum Depression (PPD)

Posttraumatic Stress Disorder (PTSD)

Suicidal Thoughts (Ever)

Other

Anxiety

Date of Diagnosis or Onset of Anxiety

Month

Day

Year

Is Anxiety Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Anxiety?

Yes

End Date of Diagnosis/Onset of Anxiety

Month

Day

Year

Depression

Date of Diagnosis or Onset of Depression

Month

Day

Year

Is Depression Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Depression?

Yes

End Date of Diagnosis/Onset of Depression

Month

Day

Year

Illicit Drug Use

Date of Onset of Illicit Drug Use

Month

Day

Year

Is Illicit Drug Use Ongoing?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Illicit Drug Use?

Yes

End Date of Illicit Drug Use

Month

Day

Year

Insomnia

Date of Diagnosis or Onset of Insomnia

Month

Day

Year

Is Insomnia Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Insomnia?

Yes

End Date of Diagnosis/Onset Insomnia

Month

Day

Year

Major Depressive Disorder

Date of Diagnosis or Onset of Major Depressive Disorder

Month

Day

Year

Is Major Depressive Disorder Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Major Depressive Disorder?

Yes

End Date of Diagnosis/Onset Major Depressive Disorder

Month

Day

Year

Obsessive Compulsive Disorder (OCD)

Date of Diagnosis or Onset of Obsessive Compulsive Disorder (OCD)

Month

Day

Year

Is Obsessive Compulsive Disorder (OCD) Ongoing Medical Condition?

Yes – Condition is ongoing

No – Condition has resolved

Are you taking any medications for Obsessive Compulsive Disorder (OCD)?

Yes

End Date of Diagnosis/Onset Obsessive Compulsive Disorder (OCD)

Month

Day