Brief Medical History for Autoimmune Diseases

1. How often do you visit your doctor for a problem?

2. Have you been diagnosed with :

3. Please state any other diseases:

4. Do you have obesity?

Yes
No

5. Do you smoke?

Yes
No

5.1 If Yes, how many cigarettes?

5.2 And for how long?

6. Is your daily activity intense?

Yes
No

7. Do you feel fatigue?

Yes
No

8. Please state if you receive any medicines or supplements

9. What bothers you more?

Age

Name *

First

Last

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Morning
Afternoon

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Email *

Message

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Brief Medical History for Autoimmune Diseases

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