Health Screening 1 Patient Information 2 Questions about your health 3 Have you ever had any of the following? 4 MALES Only: Have you ever had any of the following? 5 FEMALES Only Step description 6 MALES & FEMALES Only: Have you ever had any of the following? 7 Do you have any of these symptoms? 0% First Name Last Name Email Sex Male Female Other Date of Birth Height Weight Family Doctor Family Doctor Phone Number Family Doctor Address Apt, suite, etc. City State Select an Option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Country Select a Country Previous Next Are you allergic to or have you hade a bad reaction to any food or drugs? If so, what was the medicine or food? Yes No Allergic/bad reaction to any food or drugs details Are you on a special diet? If so, please give diet name/details: Yes No Special diet details Have you lost or gained more than 10 lbs. in 2 months? Yes No Are you any medication that makes you lose or gain weight? Yes No Do you wear contact lenses or glasses? Yes No Do you have any nutritional/eating/digestive concerns? Yes No Do you have any physical disabilities? If so, please give details: Yes No Physical disabilities details Do you have asthma? If so, please give details: Yes No Asthma details Do you have seasonal allergies? Yes No Have you had any operations? Yes No Have you ever tested positive for tuberculosis (TB)? Yes No Previous Next Serious accidents Yes No Epilepsy Yes No Neuropathy Yes No Diabetes Yes No High Blood Pressure Yes No Heart Attack or Heart Disease Yes No Cancer Yes No Stroke Yes No Non-cancerous tumors Yes No High Cholesterol Yes No Anemia Yes No Jaundice or Hepatitis Yes No Thyroid Problems Yes No Sexually Transmitted Diseases Yes No Arthritis Yes No Stomach Ulcer Yes No Please provide more information if you have or have had any of these disorders Previous Next Have you had sexually transmitted illnesses? If so, which ones? Yes No Male Sexually Transmitted Diseases Have you fathered children? Yes No Have you ever been operated on or treated for testicular/penile problem? Yes No Have you ever had problems with sterility (infertility)? Yes No Do you regularly see a urologist? Yes No At what age did you 1st have sex? N/A No Male First Sex Age Do you have any problems with your prostate or with urination? Yes No Additional Information Previous Next Previous Next Eye Yes No Sinuses Yes No Memory Yes No Breathing Yes No Bladder or Urination Yes No Arm or Leg Movement Yes No Hearing Yes No Swallowing Yes No Skin Yes No Stomach Yes No Bowels Yes No Ear Yes No Additional Information regarding anything checked? Previous Next Fainting Spells Yes No Loss of Concentration Yes No Heart Pounding Yes No Frequent Coughing Yes No Swelling of Hands or Feet Yes No Frequent Headaches Yes No Night Sweats Yes No Indigestions Yes No Hemorrhoids / Rectal Bleeding Yes No Chest Pain Yes No Dizziness Yes No Heart Fluttering Yes No Coughing Up Blood Yes No Throat Pain Yes No Extreme Tiredness Yes No Back Pain Yes No Loose Bowels Yes No Excessive Thirst Yes No Do you have any medical concerns that we should know about at this time? Yes No Medical Concerns: Submit Previous Next
