New Patient Packet

38) G.E. reflux

Yes No

39) Glaucoma

Yes No

40) Hemophilia

Yes No

41) Hepatitis, jaundice or liver disease

Yes No

42) Recurrent infections Specify

Yes No

Please specify

43) Kidney problems

Yes No

44) Low blood pressure

Yes No

45) Mental health disorders Specify

Yes No

Please specify

46) Migraines

Yes No

47) Night sweats

Yes No

48) Neurological disorders Specify

Yes No

Please specify

49) Osteoporosis

Yes No

50) Persistent swollen glands in neck

Yes No

51) Respiratory problems. If yes, specify

Yes No

Emphysema Bronchitis

52) Severe headaches

Yes No

53) Severe or rapid weight loss

Yes No

54) Sexually transmitted disease

Yes No

55) Sinus trouble

Yes No

56) Sleep disorder

Yes No

57) Sores or ulcers in the mouth

Yes No

58) Stroke

Yes No

59) Systemic lupus erythematosus

Yes No

60) Thyroid problems

Yes No

61) Tuberculosis

Yes No

62) Ulcers

Yes No

63) Excessive urination

Yes No

64) Any other diseases, condition or problem not listed above?

Yes No

Please explain:

Step 2 — Medical Information

Patient Information

Medical Info

Women Only

Conditions — Do you have any of the following diseases or problems?