Complete this Intake Questionaire

Date

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Reason For Visit

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Current Medications: (Please include OTC & supplements)

Allergies (Medications, foods, etc.):

CARDIOVASCULAR AND RESPIRATORY

High Blood PressureHeart MurmurValve DisorderAbnormal RhythmChest PainHeart AttackCardiac Surgery or StentsCongestive Heart FailurePeripheral Artery DiseaseThrombosis or DVTAneurysmAsthmaCOPDSleep ApneaShortness of BreathPulmonary HypertensionLung CancerOther Lung DisorderOther Cardiac DisorderPlease check any conditions that apply to you

GASTROINTESTINAL AND URINARY

Acid RefluxBladder DiseaseKidney DiseaseLiver DiseaseHepatitis A, B, COther

METABOLIC/ENDOCRINE/AUTOIMMUNE

Hyper/Hypo ThyroidRheumatoid ArthritisDiabetes Type I Type IIHx of DKALupusOther

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