Health History Questionaire

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All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Client Information

Last name:*

First name:*

Middle Initial:

Home Phone:

Cell Phone:

Email:

Street Address:

City:

State:

Zip

Gender

DOB

Marital status

Race

Height

feet inches

Weight

(in pounds)

PERSONAL HEALTH HISTORY

Have you ever been diagnosed or have any of the following conditions?

Cancer

Yes

No

Carpal Tunnel

Yes

No

Cholesterol Issues

Yes

No

Thyroid Issues

Yes

No

Diabetes

Yes

No

Lung Problems

Yes

No

Immune Problems

Yes

No

Heart Disease

Yes

No

Hypertension

Yes

No

Acid Reflux

Yes

No

Seasonal Allergies

Yes

No

Alzheimer's

Yes

No

Skin Wrinkles

Yes

No

>Muscle Loss

Yes

No

Osteoporosis

Yes

No

Mood Swings

Yes

No

Retina Problems

Yes

No

Homocysteine level elevation

Yes

No

Iron Deficiency / Anemia

Yes

No

Gout

Yes

No

Migraines

Yes

No

Seizures

Yes

No

Multiple Sclerosis

Yes

No

Liver Disease

Yes

No

Arthritis

Yes

No

Surgeries

Year

Reason

Year

Reason

Year

Reason

Other Hospitalizations

Year

Reason

Year

Reason

Year

Reason

Prescription & Over-the-counter Drugs

List your prescribed and over-the-counter drugs, such as vitamins and inhalers:

Coumadin

Yes

No

Warfarin

Yes

No

Drug Name

Strength

Frequency Taken

Drug Name

Strength

Frequency Taken

Drug Name

Strength

Frequency Taken

Drug Name

Strength

Frequency Taken

Drug Name

Strength

Frequency Taken

Allergies to Medications

Drug Name

Reaction You Had

Drug Name

Reaction You Had

Drug Name

Reaction You Had

Drug Name

Reaction You Had

Drug Name

Reaction You Had

Allergies to Fruits

Fruit

Reaction You Had

Fruit

Reaction You Had

Fruit

Reaction You Had

Health Habits and Personal Safety

All questions contained in this questionnaire are optional and will be kept strictly confidential.

Exercise

Sedentary (No exercise)

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)

Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Vitamins & Minerals

Are you currently taking any vitamins or minerals?

Yes

No

If so, what are you taking?

Diet

Vegetarian?

Yes

No

High Protein?

Yes

No

Caffeine

Coffee

Tea

Cola

Number of cups/cans per day?

Alcohol

Yes

No

How many drinks per week?

Tobacco

Do you use tobacco?

Yes

No

Cigarettes:

pks/day

Chew:

#/day

Pipe:

#/day

Cigars:

#/day

How many years using tobacco?:

or the year you quit?:

Family Health History

Relation

Father

Significant Health Problems:

Age:

Gender

Male

Relation

Mother

Significant Health Problems:

Age:

Gender

Female

Relation

Grandfather Paternal

Significant Health Problems:

Age:

Gender

Male

Relation

Grandmother Paternal

Significant Health Problems:

Age:

Gender

Female

Relation

Grandfather Maternal

Significant Health Problems:

Age:

Gender

Male

Relation

Grandmother Maternal

Significant Health Problems:

Age:

Gender

Female

Mental Health

From Mild to Severe

Is stress a major problem for you?

0

1

2

3

4

5

Do you feel depressed?

0

1

2

3

4

5

Do you have trouble sleeping?

0

1

2

3

4

5

If there is anything else that you feel we should know about please enter it here:

Patient's Agreement and Release

THIS AGREEMENT is made and executed on the 21 day of November 2024, between iVitamin Science, Inc. (hereinafter referred to as “iVitamin Science”) and (hereinafter referred to as “Client”).

The Client understands and agrees to the following. That information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration. That iVitamin Science™ supplements are not intended to treat, cure, or prevent any condition or disease. The Client understands and agrees that he/she should consult with their personal physician, or healthcare provider, before starting any diet, exercise, or supplementation program. That iVitamin Science™ supplements may not be appropriate for everyone; you should not take iVitamin Science™ supplements if you are pregnant or nursing.

The Client understands and agrees that he/she should read all product packaging thoroughly, and keep their health care provider informed about any dietary supplements they are taking; that they should consult their physician first if they are taking prescription drugs, or are being treated for any disease or medical condition. The Client understands and agrees that he/she should not exceed the recommended dosage; keep all supplements out of reach of children; and if you have, or suspect you have, a medical problem, contact your health care provider immediately. In addition, The Client understands and agrees that iVitamin Science™ supplements are custom formulated and packaged specifically for them. These compounded supplements cannot be returned or refunded.

Do you understand and agree to all the terms and conditions disclosed herein?

I agree.

Signature

Date: 11/21/2024

© iVitamin Science, LLC 2020