Customer Intake Form

Patient Medical History

Personal Information

Name *

Email address *

Phone *

Date of birth *

Weight (Pounds) *

Height *

Gender

Male

Female

Address

City

State

Zip code

Country

Time Zone

Who reffered you? *

Subject History

Have you ever been diagnosed with any type of cancer?

Cancer Type

Date Cancer Diagnosed

Cancer Status

Are You Diabetic?

Taking Insulin?

Vision Decrease?

If so, can you please provide more information Vision Decrease?

Vision Black Spots?

If so, can you please provide more information for Vision Black Spots?

Vision Nistagmus?

If so, can you please provide more information for Vision Nistagmus?

Muscle Weakness?

If so, can you please provide more information for Muscle Weakness?

Muscle Wasting?

If so, can you please provide more information for Muscle Wasting?

Walking Difficulties?

If so, can you please provide more information for Walking Difficulties?

Decreased Hand Strength?

If so, can you please provide more information for Decreased Hand Strength?

Fainting?

If so, can you please provide more information for Fainting?

Tingling Sensation?

If so, can you please provide more information for Tingling Sensation?

Muscle Fasciculations?

If so, can you please provide more information for Muscle Fasciculations?

Spasticity?

If so, can you please provide more information for Spasticity?

Hyperreflexia?

If so, can you please provide more information for Hyperreflexia?

Hyporeflexia?

If so, can you please provide more information for Hyporeflexia?

Loss of Memory?

If so, can you please provide more information for Loss of Memory?

Headaches?

If so, can you please provide more information for Headaches?

Sleep Disturbances?

If so, can you please provide more information for Sleep Disturbances?

Dizziness?

If so, can you please provide more information for Dizziness?

Asthma?

If so, can you please provide more information for Asthma?

Chronic Bronchitis?

If so, can you please provide more information for Chronic Bronchitis?

Chronic Cough?

If so, can you please provide more information for Chronic Cough?

Emphysema?

If so, can you please provide more information for Emphysema?

Hypertension (high blood pressure)

If so, can you please provide more information for Hypertension?

Hypotension (low blood pressure)?

If so, can you please provide more information for Hypotension

Poor Arterial Circulation?

If so, can you please provide more information for Poor Arterial Circulation?

Poor Venous Circulation?

If so, can you please provide more information for Poor Venous Circulation?

Leg Cramps?

If so, can you please provide more information for Leg Cramps?

Tired Legs?

If so, can you please provide more information for Tired Legs?

Swollen Ankles?

If so, can you please provide more information for Swollen Ankles?

Varicose Veins?

If so, can you please provide more information for Varicose Veins?

Tingling Sensation in Arms and Legs?

If so, can you please provide more information for Tingling Sensation in Arms and Legs?

Falling Asleep of the Hands and Legs?

If so, can you please provide more information for Falling Asleep of the Hands and Legs?

Ulcers or open wounds anywhere on your body?

If so, can you please provide more information for Ulcers?

Stomach or Duodenal Ulcer?

If so, can you please provide more information for Stomach or Duodenal Ulcer?

Stomach or Duodenal Ulcer Date

Hepatitis?

If so, can you please provide more information for Hepatitis?

Hepatitis Type

Icterus?

If so, can you please provide more information for Icterus?

Soft Tissue Rheumatism?

If so, can you please provide more information for Soft Tissue Rheumatism?

Articular Rheumatism?

If so, can you please provide more information for Articular Rheumatism?

Joint Pain?

If so, can you please provide more information for Joint Pain?

How severe is the pain?

Back Pain?

If so, can you please provide more information for Back Pain?

How severe is the pain?

Rheumatoid Arthritis?

If so, can you please provide more information for Rheumatoid Arthritis?

Other Rheumatic Conditions

Diabetes Mellitus?

If so, can you please provide more information for Diabetes Mellitus?

Overactive Thyroid?

If so, can you please provide more information for Overactive Thyroid?

Underactive Thyroid?

If so, can you please provide more information for Underactive Thyroid?

Adrenal Gland Dysfunction?

If so, can you please provide more information for Adrenal Gland Dysfunction?

When was your last vaccination?

Do You Smoke?

Do you drink alcohol?

If so, how frequently?

Please list any nutritional supplements you are taking

Other Significant or Chronic Illnesses

Do You Take Human Growth Hormone?

How Long Have You Taken Growth Hormone?

Human Growth Hormone Injections per Week

Hypoglycemia?

If so, can you please provide more information for Hypoglycemia?

Thyroid Problem?

If so, can you please provide more information for Thyroid Problem?

Hormone Problem?

If so, can you please provide more information for Hormone Problem?

Kidney Problem?

If so, can you please provide more information for Kidney Problem?

Heart Problem?

If so, can you please provide more information for Heart Problem?

Arthritis?

If so, can you please provide more information for Arthritis?

Prostate Problem?

If so, can you please provide more information for Prostate Problem?

Lung Problem?

If so, can you please provide more information for Lung Problem?

Stroke?

If so, can you please provide more information for Stroke?

What is the condition that needs treatment? *

⁠When were you diagnosed? *

Do you have any questions or comments?