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Simple Patient Health Information Form
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2021-03-16T19:56:27+00:00
Simple Form for Women's Health Products Desktop
PATIENT MEDICAL HISTORY FORM
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4' 9''
4' 10''
4' 11''
5'
5' 1''
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5' 5''
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5' 9''
5' 10''
5' 11''
6'
6' 1''
6' 2''
6' 3''
6' 4''
6' 5''
6' 6''
6' 7''
6' 8''
6' 9''
6' 10''
6' 11''
State Issued ID (Ex. Driver license number)
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Weight
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BMI [If Known]
Date of Birth
*
MM slash DD slash YYYY
Blood Pressure
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Pulse
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Describe Your General Health
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List any Prescription, Supplements & Over the Counter Medications you are CURRENTLY TAKING
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None
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List of Prescription
List any of your Allergies [Include Foods, Drug &, Other Allergies]
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Comments:
I have answered the above general information questions honestly and completely to the best of my knowledge.
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Check Indicates Approval
Arousal Cream Patients Only
Have you had any history of vaginal herpes?
PATIENT MEDICAL HISTORY FORM
Have You ever been Diagnosed or Treated For the Following
Alcohol/Drug Addiction
Gall Bladder Disease
Menstrual Disorder
Angina [Unstable]
Gout*
Neurologic Disorder/Migraines
Asthma
Heart Arrhythmias/Stroke*
Polycystic Ovarian Syndrome*
Autoimmune Disorder
High Blood Pressure
Pregnant / Nursing [NOW]*
Breathing Disorder /Breath Shortness
Heavy Periods
Psychiatric Disorder/Anxiety
Bulimia/Anorexia
High Cholesterol/Triglycerides
Pulmonary*
Gastrointestinal Disorder
HIV/AIDS
Recent Weight Change
Chronic Constipation
Irritable Bowel Syndrome
Serious Chronic/Acute Illness*
Crohn's Disease/Colitis*
Kidney Disease / Stones*
Sleep Problems
Deep Vein Thrombosis*
Liver/Disease
Diabetes*
Thyroid Disease*
Lung/Breathing Problems
Insulin Dependent
Have You Had Cancer?*
What Type of Cancer:
When Was Your Cancer Last Treated?
What Results Were Found During Your Last Treatment?
* Specific Medical Conditions
I have answered the above medical information questions honestly and completely to the best of my knowledge and I also will complete the Medical Consent and Agreement to Acquire HCG Products form attached.
*
Check Indicates Approval
Simple Form for Women's Health Products Mobile
PATIENT MEDICAL HISTORY FORM
FULL NAME
*
How Did You Hear About Us
Reason For HCG Treatment
*
Gender
*
PLEASE SELECT
MALE
FEMALE
Height
*
4' 1''
4' 2''
4' 3''
4' 4''
4' 5''
4' 6''
4' 7''
4' 8''
4' 9''
4' 10''
4' 11''
5'
5' 1''
5' 2''
5' 3''
5' 4''
5' 5''
5' 6''
5' 7''
5' 8''
5' 9''
5' 10''
5' 11''
6'
6' 1''
6' 2''
6' 3''
6' 4''
6' 5''
6' 6''
6' 7''
6' 8''
6' 9''
6' 10''
6' 11''
State Issued ID (Ex. Driver license number)
*
Weight
*
Desired Weight
*
State Issued ID (Ex. Driver license number)
*
BMI [If Known]
Date of Birth
*
MM slash DD slash YYYY
Blood Pressure
*
Pulse
*
Have You Done An HCG Diet?
*
How Many Pounds & Inches Lost?
Did You Like The Diet?
Describe Any Prior HCG Diet Experience
*
What Other Diets Have You Used
Describe Your General Health
*
List any Prescription, Supplements & Over the Counter Medications you are CURRENTLY TAKING
*
None
List
List any Prescription
List any of your Allergies [Include Foods, Drug &, Other Allergies]
*
Comments:
I have answered the above general information questions honestly and completely to the best of my knowledge.
*
Check Indicates Approval
Arousal Cream Patients Only
Have you had any history of vaginal herpes?
PATIENT MEDICAL HISTORY FORM
Have You ever been Diagnosed or Treated For the Following
Alcohol/Drug Addiction
Gall Bladder Disease
Menstrual Disorder
Angina [Unstable]
Gout*
Neurologic Disorder/Migraines
Asthma
Heart Arrhythmias/Stroke*
Polycystic Ovarian Syndrome*
Autoimmune Disorder
High Blood Pressure
Pregnant / Nursing [NOW]*
Breathing Disorder /Breath Shortness
Heavy Periods
Psychiatric Disorder/Anxiety
Bulimia/Anorexia
High Cholesterol/Triglycerides
Pulmonary*
Gastrointestinal Disorder
HIV/AIDS
Recent Weight Change
Chronic Constipation
Irritable Bowel Syndrome
Serious Chronic/Acute Illness*
Crohn's Disease/Colitis*
Kidney Disease / Stones*
Sleep Problems
Deep Vein Thrombosis*
Liver/Disease
Diabetes*
Thyroid Disease*
Lung/Breathing Problems
Insulin Dependent
Have You Had Cancer?*
What Type of Cancer
When Was Your Cancer Last Treated?
What Results Were Found During Your Last Treatment?
* Specific Medical Conditions
I have answered the above medical information questions honestly and completely to the best of my knowledge and I also will complete the Medical Consent and Agreement to Acquire HCG Products form attached.
*
Check Indicates Approval
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