MEDICAL HISTORY AND SCREENING FORM

This is your medical history form, to be completed prior to your first Health Forum attendance. All information will be kept confidential. This information will be used for the evaluation of your health. The form is extensive, but please try to make it as accurate and complete as possible. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out. Your answers will help us design a comprehensive program that meets your individual needs and identify others who are displaying the same symptoms.

If you have questions or concerns, we will help you with those after this form is completed. We realize that some parts of the form will be unclear to you. Do your best to complete the form. Your questions will be thoroughly addressed at our forum. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form. All information submitted is kept CONFIDENTIAL. Thank you in advance for your participation.

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