Basic Health Questionnaire
There is no charge for this service
Name
Email
Phone
Age
Sex
M
F
Race
African
African American
Asian
Caucasian
East Indian
Hispanic/Latino
Middle Eastern
Multi Ethnic
Native American
Other
Weight (pounds)
Height
Less than 5'
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
Over 6' 5"
Specify any allergies
What are health conditions for which you are currently being treated?
What herbs are you currently taking?
What nutritional supplements are you on, including multivitamins?
What prescription medications are you currently taking, include dosages?
What
over
the counter medications are you currently taking?
Have you ever had an adverse reaction
in
the past? If so, specify.
Did you report the adverse reaction to a healthcare professional?
Yes
No
