Please remember that this information is strictly confidential and will be used only to address you symptoms and/or complaints.
Please list ALL illness(heart disease, stroke, diabetes, hypertension, cancer (breast, cervical, skin, prostate, lung, blood), etc. If a member is deceased, please list age of death and cause if known.
Please list ALL prescription medications. Include ALL over the counter medications, supplements, and vitamins.
*Individual results may vary.