Health Questionnaire Please fill out our health questionnaire below Full Name * Date of Birth * MM DD YYYY Address * Phone * (###) ### #### Email * Emergency Contact Number How You Found Us? * Google, Referral, Other? Congestive Heart Failure? * Yes No Valvular Heart Disease / Heart Surgery? * Yes No Severe Renal Impairment? * (e.g. Kidney Failure, Dialysis) Yes No Heart Attack / Stroke? * Yes No History of Bleeding or Platelet Problems? * Yes No Do you take any Blood Thinners (including Plavix, Coumadin/Warfarin, Xarelto, Eliquis, or Pradaxa)? * Yes No Condition of Sodium Retention or Electrolyte Imbalance? * Yes No Edema or Water Retention? * Yes No High / Low Blood Pressure? * Yes No Severe Frequent Headaches? * Yes No Fainting / Seizures / Epilepsy? * Yes No Diabetes / Low Blood Sugar? * Yes No History of Stomach Ulcers? * Yes No Any liver conditions? (e.g. Liver Cirrhosis, Liver Disease) * Yes No Any allergies? * Yes No Do you have Sulfa Allergies? * Yes No Do you have or have had asthma? * Yes No If you have specific allergies, please list below What is your medical history? Please list below * Do you have any thyroid conditions? (e.g. Hyper/Hypothyroidism, ect.) * Yes No Are You Pregnant? *Females Only: Yes No Thank you!
