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Where did you find us?
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Who referred you?
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Anything special we need to know
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Pacemaker
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Seizure Disorder
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if yes when was last episode / t
/
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Cancer
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please list corresponding dates
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Diabetes Mellitus
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Lymphedema
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if yes where is the swelling?
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HRT (Hormone Replacement Therapy
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if yes what therapies are use?
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Contraceptive
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Form
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Renal/Nephrologic Disorder
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if present what type
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Autoimmune Disease
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if present what type?
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Currnently Pregnant
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Peptic Ulcer
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if present what location
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Psychiatric Disorder
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if present what type?
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Urine Infection
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Cardiovascular Disease
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Disorders
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Medication\Vitamin\Supplement
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Medication/Supplement
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Thyroid disease
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if yes what types
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Metal or Surgical Prostheses
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if yes what prostheses and when
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Dermatoses
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if yes what skin disorders
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Musculoskeletal disease
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if yes what types
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Digestive Disorder
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if yes what types
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Gynecologic disorder
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if yes what types
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Neurologic disorder
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if yes what types
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Immune System Disorder
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if yes what types
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HIV
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if yes what are they?
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Other currently treated med cond
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iLipo Ultra Consent
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