| Please provide your medical history by filling in the form below: |
| * First Name |
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| * Last Name |
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| Gender: |
Male Female
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| * Birth Date: |
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| * Street/PO Box: |
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| * City/Town: |
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| * State/Province: |
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| * Zip/Postal Code: |
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| * Country: |
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| E-Mail |
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| Tuberculosis: |
Yes No Relationship: |
| Diabetes: |
Yes No Relationship: |
| Kidney Disease: |
Yes No Relationship: |
| Heart Disease: |
Yes No Relationship: |
| Arthritis: |
Yes No Relationship: |
| Stomach Disease: |
Yes No Relationship: |
| Asthma/Hay Fever: |
Yes No Relationship: |
| Epilepsy, Convulsions: |
Yes No Relationship: |
| Scarlet Fever: |
Yes No |
| Insomnia: |
Yes No |
| Measles: |
Yes No |
| Frequent Anxiety: |
Yes No |
| German Measles: |
Yes No |
| Frequent Depression: |
Yes No |
| Mumps: |
Yes No |
| Worry/Nervousness: |
Yes No |
| Chicken Pox: |
Yes No |
| Recurrent Headaches: |
Yes No |
| Malaria: |
Yes No |
| Recurrent Colds: |
Yes No |
| Gum or Tooth Trouble: |
Yes No |
Head Injury/
Unconsciousness: |
Yes No |
| Sinusitis: |
Yes No |
| Eye Trouble: |
Yes No |
| Surgery (explain below): |
Yes No |
| Allergies (explain below): |
Yes No |
| Ear/Nose/Throat Trouble: |
Yes No |
| Pain/Pressure in the Chest: |
Yes No |
| Chronic Cough: |
Yes No |
| Heart Palpitations: |
Yes No |
| High/Low Blood Pressure: |
Yes No |
| Rheumatic Heart Fever/Heart Murmur: |
Yes No |
| Weakness/Paralysis: |
Yes No |
| Venereal Disease: |
Yes No |
"Trick" Knee/
Shoulder, etc.: |
Yes No |
| Back Problems: |
Yes No |
| Tumor/Cancer/Cyst: |
Yes No |
| Jaundice: |
Yes No |
| Gallbladder/Gallstones: |
Yes No |
| Recurrent Diarhea: |
Yes No |
| Rupture/Hernia: |
Yes No |
| Recent Weight Gain/Loss: |
Yes No |
| Dizziness/Fainting: |
Yes No |
| Disease/Injury of Joints: |
Yes No |
| Frequent Urination: |
Yes No |
| Stomach/Intestinal Trouble: |
Yes No |
| A. Has your physical activity been restricted during the past five years? If yes, give reasons and duration below. Yes No |
| B. Have you had difficulty with school, studies, or teachers? If yes, give details below. Yes No |
| C. Have you received treatment or counseling for a nervous condition, personality, or character disorder, or emotional problem? If yes, give details below. Yes No |
| D. Have you ever had any illness or injury and been hospitalized other than already noted? If yes, please explain. Yes No |
| E. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past five years? If other than routine checkups, please explain. Yes No |
| F. Have you ever been rejected for or discharged from military service because of physical, emotional, or other reasons? If yes, please explain. Yes No |
Explanations:
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| Irregular Periods: |
Yes No |
| Severe Cramps: |
Yes No |
| Excessive Flow: |
Yes No |
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Please verify that all required fields have been filled and that all information is to your knowledge accurate. Once you have looked over the form for accuracy, please submit this form.
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