• Name
  First Last
• Phone
  ### - ### - ####
• Age
• Gender
  Please selectMaleFemale
• Describe your needs
• Check all that apply to you or your immediate family (parents, siblings, grandparents)
  Asthma

  Cancer

  Cardiac Disease

  Diabetes

  History of Back Pain

  Hypertension

  Psychiatric Disorders

  Seizure Disorder

  Stroke
• Check all symptoms you are currently experiencing
  Allergy

  Cardiovascular

  Chest Pain

  Connective Tissue

  Diabetes

  Eating Disorder

  Ear / Nose / Throat

  Eye

  Fever

  Gastrointestinal

  Genitourinary

  Hemtalogical

  Lymphatic

  Musculoskeletal Pain

  Neurological

  Psychiatric

  Respiratory

  Skin

  Weight Gain

  Weight Loss

  Other
• Please list any medication allergies that you have
• Please list any medications you are currently taking
• Are you currently pregnant, or is there a possibility that you are pregnant?
  Yes

  No
• Are you currently using or do you have a history of tobacco use?
  Yes

  No
• Are you currently using or do you have a history of illegal drug use?
  Yes

  No
• Do you feel you are at risk for falls or falling injuries?
  Yes

  No
• Please describe your alcohol consumption
  Daily

  Weekly

  Monthly

  Occasionally

  Rarely

  Never