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Question 1 : What is/are the main medical problem(s) which you currently have or have had in the past?*:
HIV/AIDS Nausea Fibromyalgia Seizures Arthritis Muscle Spasm Migraine Headaches Anxiety Chronic Pain Glaucoma Cancer Trouble Sleeping Loss of Appetite Weight Loss Other
Question 2 : Are you RENEWING your recommendation (Have you had a recommendation in the last 10 years)*:
yes
no

Select an answer please
Question 3. Do you currently use specific medications for your medical condition?:
yes
no

Select an answer please
Question  4. Are you taking any prescription medications or herbs? *:
yes
no

Select an answer please
Question  5. Do you have any allergies to any medications? *:
yes
no

Select an answer please
Question 6. Have you ever had any surgeries or been hospitalized?:
yes
no

Select an answer please
Question 7. Do you exercise?:
yes
no

Select an answer please
Question 8. Do you smoke tobacco?:
yes
no

Select an answer please
Question 9. Do you drink alcohol?:
yes
no

Select an answer please
Question 10. Are there health/medical problems that occur frequently in your family?:
yes
no

Select an answer please
Question 11. Have you experienced or been diagnosed with any of the following *:
Depression
Bipolar Disorder
Schizophrenia
Suicidal thoughts
ADHD
0 None

Question  12. Do you have a primary care provider? *:
yes
no

Select an answer please
Question 13. When was the last time you saw your doctor/specialist about these complaints? (mm/dd/yyyy)
Enter date, please (format: mm/dd/yyyy)

 

If available, you will have an ability to upload to your portal previous Recommendation or any other medical records as related to the medical condition(s) identified above.

Question 14. Provide details on the medical condition and diagnosis: