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GIOSTAR MEXICO
Health History Information
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Name
*
Your answer
How did you find out about us?
*
Google
Facebook
Referral
Other:
Date of Birth
*
Please include your date of birth (month / day / year)
MM
/
DD
/
YYYY
Gender
*
Male
Female
Contact Phone Number
*
Your answer
Contact e-Mail
*
Your answer
Please name your medical condition or disease
*
Your answer
Weight:
*
Your answer
Height:
*
Your answer
The reason why I need this examination is:
*
Your answer
When were you diagnosed with this medical condition?
*
Your answer
Please list all medication you are currently taking
*
Your answer
Please list all supplements you are currently taking
*
Your answer
Is your general health good?
*
Yes
No
If your last answer was no, please explain:
Your answer
Has there been a change in your health within the last year?
*
Yes
No
If your last answer was yes, please explain:
Your answer
Have you gone to the hospital or emergency room or had a serious illness the last three years?
*
Yes
No
Are you being treated by a physician now?
*
Yes
No
If your last answer was yes, please explain:
Your answer
Are you in pain now?
*
Yes
No
If your last answer was yes, please explain:
Your answer
Have you done any spinal cord surgery?
*
Yes
No
If your last answer was yes, please explain:
Your answer
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