Adult Medical History Adult Medical History Form (Complete Version) Step 1 of 5 20% First Name(Required) Middle Initial(Required) Last Name(Required) Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Physician’s Name Physician's Address Physician's Phone Number2. Are you under a physician’s care?(Required) Yes No Since when?(Required) And why?(Required) 3. When was your last complete physical exam?(Required) 4. Are you taking any medication or substances?(Required) Yes No If yes, please list:(Required) If no, type "none":(Required) 5. Do you routinely take health related substances? (Vitamins, herbal supplements, natural products)(Required) Yes No 6. Are you allergic to any medications or substances?(Required) Yes No If yes, please list:(Required) If no, type "none":(Required) 7. Do you have any other allergies or hives? .(Required) Yes No 8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications?(Required) Yes No 9. Are you sensitive to any metals or latex?(Required) Yes No 10. Are you pregnant or suspect you may be?(Required) Yes No 11. Do you use any birth control medications?(Required) Yes No 12. Have you ever been treated for or been told you might have heart disease?(Required) Yes No 13. Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?(Required) Yes No 14. Have you ever had rheumatic fever?(Required) Yes No 15. Are you aware of any heart murmurs?(Required) Yes No 16. Do you have high or low blood pressure?(Required) Yes No Please Explain:(Required) 17. Have you ever had a serious illness or major surgery?(Required) Yes No Don't Know If so, explain(Required) 18. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition?(Required) Yes No 19. Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?(Required) Yes No 20. Do you have inflammatory diseases, such as arthritis or rheumatism?(Required) Yes No 21. Do you have any artificial joints/prosthesis?(Required) Yes No Don't Know 22. Do you have any blood disorders, such as anemia, leukemia, etc?(Required) Yes No 23. Have you ever bled excessively after being cut or injured?(Required) Yes No 24. Do you have any stomach problems?(Required) Yes No 25. Do you have any kidney problems?(Required) Yes No 26. Do you have any liver problems?(Required) Yes No 27. Are you diabetic?(Required) Yes No 28. Do you have fainting or dizzy spells?(Required) Yes No 29. Do you have asthma?(Required) Yes No 30. Do you have epilepsy or seizure disorders?(Required) Yes No 31. Do you or have you had venereal or any sexually transmitted disease?(Required) Yes No 32. Have you tested HIV positive?(Required) Yes No 33. Do you have AIDS?(Required) Yes No 34. Have you had or do you test positive for hepatitis?(Required) Yes No 35. Do you or have you had T.B.?(Required) Yes No 36. Do you smoke, chew, use snuff or any other forms of tobacco?(Required) Yes No 37. Do you regularly consume more than one or two alcoholic beverages a day?(Required) Yes No 38. Do you habitually use controlled substances?(Required) Yes No 39. Have you had psychiatric treatment?(Required) Yes No 40. Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?(Required) Yes No 41. Do you have any disease condition, or problem not listed? If so, explain 42. Is there anything else we should know about your health that we have not covered in this form? 43. Would you like to speak to the Doctor privately about any problem?(Required) Yes No "I certify that the above information is complete and accurate"(Required) First Last By typing your full name here, you are electronically signing this document. Today's Date(Required) MM slash DD slash YYYY Δ
