Medical History

Patient Information

None

Anxiety

Blood Clots

Hepatitis C

Hypertension

Pregnant or Nursing

Myocardial Infarction

Seizure Disorder

Thyroid Disease

Other

Check current patient problems

Exercise Activity

Moderate

Vigorous

Sedentary

Tobacco Use

No

Daily

Weekly

Less

Former User

Alcohol Use

No

Daily

Weekly

Less

Former User

Are you currently taking supplements or prescription medication?

Yes, I am.

I do not take any medications.

Are you allergic to any medications?

No

Yes. Please list

Other:

Are you allergic to any medications?

Have you had any surgeries in the past 5 years?

Yes

No

Other

Have you had any surgeries in the past 5 years?

Previous Surgical History

None

Gastric Bypass

Bilateral Tubal Ligation

Hysterectomy

TAH/BSO

Other:

Previous Surgical History

Signature of Patient/Responsible Party

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