• Personal Health Information

  • What is your Gender?
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  • Which race do you most closely identify with?

  • Marital Status
  • Please advise us of all your goals

  • Family History

  • Has anyone in your immediate family (blood relative) ever had any of the following diseases or conditions?

  • Please specify the type(s) of cancer in your family

  • Thyroid

  • Have you been diagnosed with a thyroid problem?
  • Have you been checked for thyroid problems?

  • Allergies

  • Do you have any allergies to medications, foods or environmental allergens?

  • Medications / Supplements

  • Are you currently taking any medications or supplements?
  • Please enter you current weight and height
  • Have you ever had problems with your weight, please describe the problem:

  • How often do you consume alcohol?
  • Have you ever smoked cigarettes, cigars, marijuana or a pipe?
  • Do you use or do you have history of using illegal drugs?
  • Have you ever been vaccinated?
  • Have you ever had a reaction to a vaccine?
  • Have you ever had surgery?

  • Head, Ears, Eyes, Nose, Thoat

  • Do you have or have you ever had eye, ear, nose, mouth or throat problems?

  • Lungs

  • Do you have or have you ever had lung problems (e.g., asthma, bronchitis, shortness of breath, pneumonia)?

  • Heart

  • Do you have or have you ever had cardiovascular problems (e.g., chest pain, heart attack, heart valve problems, high blood pressure, leg cramps)?

  • Gastrointestinal

  • Do you have or have you ever had gastrointestinal problems (e.g., blood in your stool, cramping, hepatitis, liver disease, pancreas problems)?

  • Men's Health

  • Do you have or have you ever had any prostate, erection or testicular problems?

  • Women's Health

  • Date of last menstrual period
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  • Do you have irregular or painful periods?
  • Do you have or have you ever had any breast problems?
  • Do you have or have you ever had any gynecologic problems?

  • Symptoms Checklist

  • Check if you have ever experienced any of the following symptoms:
  • Certain Waivers under HIPAA. (a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician. (b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following: E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI; Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.

  • I agree to accept responsibility for payment of all charges relating to the services provided to me, regardless of the outcomes of the services or whether any insurance applies.

  • By signing below, you, the patient of Sunridge Medical (or the legal representative or parent of the patient), are requesting and authorizing
    Sunridge Medical Wellness Center to perform services and to provide you with recommendations on optimizing your present and long-term
    health goals.

  • Today's Date*
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