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Anti-Aging
Anit-Fungal
Arousal Cream
B-12 Injections
Glutathione
Lipotropics
Biotin (Vitamin B7) Injection
Best NAD+ Supplement
NAD+ Injection
Ascorbic Acid Injection
Cholecalciferol Injection (D3)
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Patient Health Information Form
admin
2021-02-11T18:14:58+00:00
Black Friday Form Destop
PATIENT MEDICAL HISTORY FORM
Full Name
*
How Did You Hear About Us
Gender
*
PLEASE SELECT
MALE
FEMALE
Height
*
PLEASE SELECT
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
*
BMI [If Known]
Date of Birth
*
MM slash DD slash YYYY
Blood Pressure
*
Pulse
*
Describe Your General Health
*
List any Prescription, Supplements & Over the Counter Medications you are CURRENTLY TAKING
*
None
List
List of 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
Black Friday Form 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
*
Your Highest Weight
*
BMI [If Known]
Date of Birth
*
MM slash DD slash YYYY
Blood Pressure
*
Pulse
*
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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