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Health history form
Name*
How did you find us?*
Google
Bing
Social Media (Facebook, Youtube, Instagram, LinkedIn, Twitter)
Health Pod
Referral
Other
Date of Birth
Month*
January
February
March
April
May
June
July
August
September
October
November
December
Day*
1
2
3
4
5
6
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year*
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
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1955
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1957
1958
1959
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1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Age (number)
Gender*
Male
Female
Contact Phone Number*
Contact e-Mail*
Please name your medical condition or disease*
Weight*
Height*
The reason why I need this examination is*
When were you diagnosed with this medical condition?*
Please list all medication you are currently taking*
Please list all supplements you are currently taking*
Is your general health good?*
Yes
No
If your last answer was no, please explain:
Has there been a change in your health within the last year?
Yes
No
If your last answer was yes, please explain:
Have you gone to the hospital or emergency room or had a serious illness the last three years?
Yes
No
Are you being treated by a physician now?
Yes
No
If your last answer was yes, please explain
Are you in pain now?
Yes
No
If your last answer was yes, please explain
Have you done any spinal cord surgery?
Yes
No
If your last answer was yes, please explain
Please select which of the following have you experienced
Chest pain (angina)
Fainting spells
Recent significant weight loss
Fever
Night sweats
Persistent cough
Bleeding problem
Blood in urine
Blood stools
Diarrhea or constipation
Frequent urination
Difficulty urinating
Ringing in ears
Headaches
Dizziness
Blurred vision
Bruise easily
Vomiting
Jaundice
Dry mouth
Excessive thirst
Difficulty swallowing
Swollen ankles
Joint pain / stiffness
Shortness of breath
Sinus problems
None
Other (explain)
Have you had or do you have any of the following
Heart disease
Heart attack
Artificial joint
Stomach problem
Heart defects
Heart murmurs
Rheumatic fever
Skin disease
Hardening of arteries
High blood pressure
Seizures
HIV / AIDS
Surgery
Hospitalization
Diabetes
Cancer / tumor
Chemotherapy
Radiation
Arthritis
Rheumatism
Lung disease
Kidney disease
Stroke
Eating disorders
Osteoporosis
Thyroid disease
Tuberculosis
Hepatitis
Sexually Transmitted Disease (STD)
Herpes
Cold sores
Anemia
Liver disease
Eye disease
None
Other (explain):
Are you allergic to or have you had reaction to any of the following
Aspirin
Darvon
Codeine
Latex
Local anesthetic
Valium
Demerol
Penicillin
Food
Erythromycin
Tetracycline
Vicodin
Percodan
Nitrous oxide
Metal
Other (explain):
Are you taking or have taken any of the following in the last three months:
Recreational drug
Weight loss medicine
Cortico-steroids
Tobacco in any form
Alcohol
Bisphosphonate (Fosamax)
Antibiotics
Supplements
Aspirin
Other (explain):
Women only:
Are you or could you be pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking birth controlling pills?
Yes
No
All patients
Do you have any other diseases or medical condition NOT listed on this form?*
Yes
No
If your last answer was yes, please explain
Preferred Location
Los Algodones, Baja California (bordered with Yuma, Arizona)
Cancun Riviera
Guadalajara
Estimated Month to Schedule
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