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MEDICAL HISTORY FORM

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 SECTION 1. PERSONAL INFORMATION

 
First Name: A value is required. 
Last Name: A value is required.
Email: A value is required.
Date of Birth:
Gender:
Weight:
Height:
Pulse:
Blood Pressure:
ADDRESS PHONE NUMBERS

Address:

Home:
City: Work:

State/Province:

Mobile:

Zip:

Fax:

Country:

Occupation:
       

 SECTION 2. CONFIDENTIAL MEDICAL HISTORY

Family History: Does an immediate family member currently have or ever had any of the following? If yes, please check and explain below:
Condition: YES NO

Cardiovascular disease:

Diabetes, thyroid or other

Endocrine Disorder

Hypertension

Lipid Disorder

Other forms of cancer

Prostate cancer

Other illnesses

Please use this space to explain any Yes answer and write any additional information:

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 Lifestyle Information

  YES NO   DETAILS

Do You Smoke?

If Yes how much do you smoke per day?

Do you drink alcohol?

If Yes how much do you drink per week?

Are you taking over the counter supplements?

If Yes, list Name and Quantity per day/week:

Do you exercise regularly?

If Yes, please describe:

 Diagnosed History of Disease: 

Do you currently have or ever had any of the following?
If yes, please explain in the box below:

Choose Yes or No for each: Yes No Choose Yes or No for each: Yes No

Any known deficiency including minerals and electrolytes

Use of medications:
(if yes, list medications below)

Blood disorders

Immune disorders

Cancer

Chemical Dependency

Carpal Tunnel syndrome

Lung disorder

Orthopedic or muscle disorder including fracture or joint disorders

Heart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack

Allergies to Medications

Upper respiratory

Edema / excess fluid retention

Poor wound healing

Emotional disorders / depression

Renal disease

Genital – Urinary disorder

Other illnesses

Hyperlipidemia

Hypertension

Neurological disorders, Thyroid, Diabetes or other endocrine disorder including insulin resistance, or diabetes

Arthritis

Bursitis Rheumatism
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Please use this space to explain any Yes answers for allergies to medications, surgeries, hospitalizations, disease, or any additional information:

List all the medications you are taking:
Please be specific (Name, dosage, etc.) or specify "none"

  YES NO   DETAILS

Prior history of Steroids or hormones?

If Yes,
Please Select:

Tes
Deca
Winstrol
HGH
thyroid
Other

Female:
Est
Premarin
Proges
Provera
birth control

Type / Dose / Frequency

Last Used?
  YES NO   DETAILS

Prior Medical Records / Labs?

Any Side Effects?

Used estrogen-blocker?

   
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PRC AND ITS PHYSICIANS DO NOT TREAT S FOR ATHLETIC PERFORMANCE OR ENHANCEMENT

Questions for Treatment:
Do you currently have or ever had any of the following symptoms?
If Yes, please check and explain below:

 

Yes

No

 

Yes

No

Decreased desire and ability to exercise

Increasing sagging muscles or breasts:

Cold or heat intolerance

Increasing wrinkles

Decreased energy or endurance

Increasingly stressed

Decreased sense of well-being

Decreasing size of testicals

Decreasing memory

Loss of interest in sex

 

Yes

No

 

Yes

No

Decreasing muscle strength

Muscle loss

Loss of concentration, sociability, activity

Progressive osteoporosis, decreasing bone mass or stooped posture

Depression

Sagging, loose or thin skin

Difficulty sleeping

Thinning or loss of hair

Hot flashes

Urogenital atrophy

Increased lack of drive

Headaches/ Migraines

Increasing fat deposits about abdomen and/or thighs

Weight loss – Unexplained

Increasing mood swings

Currently Pregnant?

Other

Sore Muscles, join pain(s) or swelling?

Please use this space to explain “other” and write any additional information:


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 SECTION 3. SIGNATURE

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Please make a selection. I attest I am not a professional or amateur athlete.
Please make a selection. I attest I am not seeking medical treatment for any body enhancement
Please make a selection. I attest I am not seeking treatment for body building or performance enhancement of any kind.
Please make a selection. I am seeking this treatment for legitimate medical purposes.
Please make a selection.

A value is required.

A value is required.
Signature Date

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PRESCRIBING PROCEDURES LEGAL COMPLIANCE
ARC will not dispense a prescription unless a clinical need exists based on required lab work, physician consultation, and current medical history provided either through a client's personal physician or an associate physician of Ageless Rejuvenation Center. Agreeing to lab work does not automatically guarantee clinical necessity or a resulting prescription. No claim or opinion made byAgeless Rejuvenation Center media is intended to be, or should be construed to be, medical advice. Please consult with a healthcare professional before starting any therapeutic program.