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Medical History Forms
Medical History
Full Name
*
Date of Birth
*
Email
*
Phone Number
General Symptoms
Easily irritated
Tire very quickly
Lack of energy
Lack of sex drive
Night blindness
Shortness of breath
Gasping for air at times
Susceptible to colds
Feeling of faintness
Crying spells
Forgetfulness
Anxiety attacks
Indecisiveness
Apathy toward everything
Unsteady when walking
Digestive & Urinary
Indigestion or acid reflux
Nausea
Burning urination sensation
Infrequent urination
Excessive urination
Blood in the urine
Urine obstruction
Incomplete bowel evacuations
Constipation
Diarrhea
Hard, soapy stools
Infrequent bowel elimination
Gas pains
Constantly passing gas
Burping up bile
Stomach cramps
Abdominal soreness
Stomach swells up
Sweet tooth
Neurological & Sensory
Headache (back of neck & head)
Headaches around the eyes
Headaches on top of the head
Sensitivity to loud noises
Sensitive to bright lights
Dark spots in front of eyes
Blurred vision
Double vision
Narrowed, tube-like visual field
Tics or tremors
Trembling hands
Numbness and tingling
Difficulty in talking
Drooping eyelids
Skin, Hair & Nails
Dry or flaky skin
Rashes that are food-related
Hives
Puffiness around the eyes
Dark circles below the eyes
Yellow eyes
Bruise easily
Loss of hair
Split nails
Foul body odor
White-coated tongue
Submit
Please list any complaint in the order of importance
Please list all surgeries that have been performed on you
Please list all medications that you are currently taking and for what purpose
Please list all medications that you took in the past in large quantities
Please list all nutritional supplements or herbs that you are taking
Blood Pressure/ Normal Heart Rate
Occupation
Submit
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