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| Self: | If Yes, Specify Condition Below: |
1. OVERALL HEALTH: | | |
2. EAR, NOSE, THROAT (i.e. Sinus Problems, Sleep Apnea, Vertigo, Hearing Loss): | none | |
3. CARDIOVASCULAR (i.e. High Blood Pressure, High Cholesterol, Abnormal Rhythm, Stroke, Heart Attack): | none | |
4. RESPIRATORY (i.e. Asthma, COPD, Emphysema, CF, Lung Cancer): | none | |
5. GENITAL, KIDNEY, BLADDER (i.e. Kidney Stones, PKD, Chronic UTI, Enlarged Prostate): | none | |
6. MUSCLES, BONES, JOINTS: (i.e. Osteoarthritis, Rheumatoid Arthritis, Joint Replacement, Fibromyalgia) | none | |
7. SKIN (i.e. Psoariatic Arthritis, Psoariasis, Melanoma, Rosacea, Cold Sores): | none | |
8. NEUROLOGICAL (i.e. Stroke, Dementia, Parkinsons, ALS, Alzeimer's, Epilepsy, Migraines, MS): | none | |
9. PSYCHIATRIC (i.e. Depression, Anxiety, Mood / Personality Disorders, Schizophrenia): | none | |
10. ENDOCRINE (i.e. Diabetes, Thyroid Disorder, Adrenal Disorder, Pituitary Disorder): | none | |
11. BLOOD / LYMPH (i.e. Sickle Cell, Anemia, Lymphoma, Leukemia, Bleeding / Clotting Disorders): | none | |
12. ALLERGIC / IMMUNOLOGIC (i.e. Autoimmune Disease, Immunocompromised, Hay Fever): | none | |
13. GASTROINTESTINAL (i.e. Crohn's, Ulcerative Colitis, Celiac, IBS, Chronic Diarrhea, Liver Disease): | none | |
14. OTHER SYSTEMIC DISEASES: | none | |
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