Is this also your mailing address?
Have you been to the hospital in the past year?
Please list any medical illnesses or problems and provide details
Have you ever had any medical issues or problems that are now resolved?
Resolved Medical History
Please list any resolved medical illnesses or problems and provide details
Family Medical History
Please indicate any major conditions/illnesses that your immediate family members have had
This is to help understand environmental risks to your health that you may have been exposed to, such as living in Belle Glades with excessive farm burning occur and that could contribute to COPD risk due to the inhalation of smoke.
This is to help understand occupational risks to your health that you may have been exposed to, such as an electrician being exposed to lead.
Ex. I was exposed to asbestos for 25 years and second hand smoking for 20 years
Do you have any known medication allergies?
Medication side effects can be described on the next page.
Do you have any known environmental allergies?
Pets, Food, Plants, and Intolerances
Prescriptions, Supplements, and Over The Counter
Has a medication ever been discontinued in the past for any significant reason?
This could be due to but not limited to price, no improvement of symptoms, or worsening of symptoms.
Are you currently experiencing any side effects from your medication?
Have you ever had any surgeries?
Do you plan to have any surgeries?
If you haven’t already booked your appointment please got to
to select a package, a date, and time.
Have you ever had a genetic test before?
Such as Ancestry, 23andMe, GeneSight etc.
Would you like to know your genetic risk for developing Alzhiemer’s Disease?