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For CLINIC visits, click this button
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For TO GO visits, click this button
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Please tell us why you're here
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How did you find out about the Remedy Room?
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Allergies to Medicine?
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List Meds You're Allergic To
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List of Prescription Medications
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Medicine continued.
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Past Medical History/Diagnoses Given
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Mom and Dad Past Medical Problems?
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Please list any Surgeries you've had
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Do you Smoke Cigarettes? How Much? How Often?
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Do you use vape products?
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Drink Alcohol? How Much? How Often?
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Marital Status
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Number of Children/Ages
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Number of Children
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Are you pregnant or nursing?
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What type of work are you in?
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When was last Bloodwork drawn?
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Have you eaten today?
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If yes, what time did you eat and what did you eat?
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Please tell us why you're here
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How did you find out about the Remedy Room?
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Allergies to Medicine?
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List Meds You're Allergic To
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List of Prescription Medications
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Past Medical History/Diagnoses Given
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Please list any Surgeries you've had
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Are you pregnant or nursing?
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History of heart disease?
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Are you of Mediterranean Descent?
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Ever had Abnormal EKG? Stress test?
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History of Lung Disease (COPD?)
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Kidney Disease/Abnormal BUN/Cr?
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History of Liver Disease?
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History of heart disease?
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Are you of Mediterranean Descent?
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Ever had Abnormal EKG? Stress test?
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History of Lung Disease (COPD?)
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Kidney Disease/Abnormal BUN/Cr?
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History of Liver Disease?
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For O SHOT visits, please click this button
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P SHOT (questions are for the LAST 6 MONTHS)
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Leak urine when you cough or sneeze?
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Confidence to keep erection
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Leak urine when you bend down or lift something?
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Time your erections are hard enough for penetration
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Leak urine when you walk quickly, jog, or exercise?
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Able to maintain erection after penetration
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Leak urine while undressing to use the restroom?
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Difficulty maintaining erection to completion of sex
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Urgency causing leakage before reaching the toilet
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How often was sexual intercourse satisfactory?
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Rush to the bathroom due to urgency
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For CHELATION visits, click this button
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For HIGH DOSE C visits, click this button
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General
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Neuro/Misc
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Symptoms
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Symptoms
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Eyes/Ears/Nose/Throat
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Heart/Lungs/Vascular
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Symptoms
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Symptoms
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Kidneys
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GI
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Symptoms
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Symptoms
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Other
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Symptoms/Diagnoses
• • •
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Exposure History
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Select which ones you have had exposures to
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Hospital/Oncologist Name + Phone #
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What type of cancer do you have?
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When were you first diagnosed?
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What stage is your cancer?
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Has your cancer spread? If so, where?
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Dates/Result of most recent scans and lab
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Treatments/Surgeries so far and results?
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Any side effects currently from treatment?
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