Form

Please check the following conditions that apply to you

First & Last Name

RESPIRATORY :

EmphysemaAsthmaPneumoniaUpper RespiratoryInfection BronchitisPulmonary Embolus

CARDIOVASCULAR :

Heart AttackChest PainLipids.Heart FailureHigh Blood Pressure TriglyceridesHeart MurmurIrregular Heart Beat Coronary Artery Disease

GASTROINTESTINAL :

HepatitisHepatitis AGallstonesCirrhosisHepatitis BUlcersLiver FailureHepatitis CReflux

ENDOCRINE :

DiabetesHypothyroidismHashimotoPituitaryParathyroid Hyperthyroidism

NEUROLOGIC :

HeadacheSeizuresMigrainesStrokeSpeech ProblemBell ’s palsyTremorMyasthenia GravisMultiple Sclerosis

UROLOGY :

Kidney StonesRenal FailureNephritisBPH

EYES :

CataractsBlindnessGlaucoma

MUSCULO SKELETICAL :

ArthritisTMJDegenerative Disc DiseaseGOUT Spinal StenosisFibromyalgia

HEMATOLOGIC :

AnemiaLymphoma Bleeding DisordersLeukemia (CLL)Deep Venous Thrombosis

PSYCHIATRIC :

DepressionAnxietyBi-Polar Disorder

OTOLOGY :

Hearing Loss Tinnitus/Ringing in earsVertigo/DizzinessImpacted CerumenExternal Ear InfectionPerforation of Eardrum

*Alcohol Use :

NoneMinimalModerateHeavy

*Cancer :

YesNo

*Tobacco Use :

NoneMinimalModerateHeavy

Phone no :

*Your Phone Number