Brief Medical History for Chronic 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?

5. Have you been diagnosed with an Autoimmune Disease?

6. Have you been exposed to Chemicals or Toxic Substances?

7. Do you smoke?

7.1 If Yes, how many cigarettes?

7.2 And for how long?

8. Is your daily activity intense?

9. Do you feel fatigue?

10. Please state if you receive any medicines or supplements

11. What bothers you more?

Age

Name *

First

Last

Preferred Contact Hours

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Email *

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