Personal Medical History
First name
Last name
DOB
MM/DD/YYYY
Date:
Please check if you have been treated in the past for any of the following:
Anemia / Blood Disease
Head Injury or Concussion
Anorexia Nervosa
Heart Problems / Murmur
Anxiety
Hepatitis
Arthritis
Hypertension (high blood pressure)
Asthma
Immune System Disorder
Sickle Cell Disease/ Trait
Joint / Muscles/ Tendon Problem
Allergy/ Hay Fever
Sexually Transmitted Disease
Bulimia
Kidney Stones
Cancer
Measles ( Rubella)
Inflammatory Bowel Disease
Mononucleosis
Crohn's Disease
Obesity
Diabetes
Stomach Ulcer
Depression
Rheumatic Fever
Seizure Disorder (Epilepsy)
Thyroid Disorder
Alcohol/Drug Use
Tuberculosis
Use Tobacco
Scarlet Fever
Malaria
TMJ (jaw problem)
Lyme Disease
Hypoglycemia
Hives
Digestive Disorders
Blood Clot/Phlebitis
Transfusions
Urinary Tract Infection
Are you
CURRENTLY
under the care of a physician or clinical practitioner for any conditions(s)?
Yes
No
Please specify
Are you taking any medication for any of the conditions checked above?
Yes
No
List all Medical Issues/ Concerns:
Please Specify medicine :
Have you ever taken any supplements or vitamins in an effort to gain or lose weight or improve your performance?
Yes
No
Please specify:
Have you ever experienced chest pain, dizziness or loss of consciousness during or after exercise?
Yes
No
Please specify:
Has anyone in your family experienced a sudden, serious cardiac event before the age of 40?
Yes
No
Please specify:
Past Surgeries/ Operations:
Allergies
Are you allergic to anything including prescription medications, over-the-counter medications, foods, insects, inhalants, latex?
Yes
No Known allergies
Allergic to and reaction:
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