Medical History Form

Thank you for taking the time to fill out this questionnaire.

This will allow us to address your concerns and explain what Sanoviv can do for you. After submitting this form, please contact your admissions coordinator to schedule the date and time of your call.

* First Name

 

Middle name

 

Last Name

 

Gender

Male Female

Date of birth

 dd   yyyy: 

Address

 

City

 

State / Province

 

Zip/ Postal Code

 

Country

Occupation (Please write up to four words).

 

Preferred phone number to receive Sanoviv´s call, please include the country code, area code and phone number.

Home Phone   * Cell
Skype account

Email Address

 

Religion

 

Marital Status

 

Person to contact in case of emergency

 

Phone number of contact person

 

Relationship with contact person

 

What is your primary language?

 

Do you require translation in order to communicate in English?

Yes No

How did you hear about Sanoviv?

Online Search Friend, Relative
Doctor Referral USANA
In a Lecture In a Magazine, Books
Other

Please summarize your current health status.

 

What is the diagnosis that you have received? (Please include date of the diagnosis). If you do not have a diagnosis, what are your main health issues?

 

What do you want to achieve at Sanoviv?

 

In your opinion, What might have contributed or caused some of your main health complaints? Did anything significant happened in your life close to the time of onset?

 

Describe briefly the chronological evolution of your symptoms or/and diagnosis. Please include dates if possible.

 

What treatments have you done in the past and which ones are you currently receiving? Please specify dates if possible.

 

How physically independent are you?

Totally independent I need help from others to move from one place to another

Have you had any medical tests recently? If yes, please list the name of the test, date, and result.

 

What do your doctors say about your condition?

 

Do you have any known food allergies (that will cause an anaphylactic reaction)

No Yes

Do you have any known food sensitivities (those that may cause mild reactions)

No Yes

Please note any food allergies or sensitivities for your companion, if applicable

 

Have you ever been hospitalized for mental/emotional problems?

Yes No

Do you have any sensitivities or allergies to medication?

Yes No

Have you had any surgery? if yes, elaborate.

 

Have you ever been diagnosed with an infectious disease?

Yes No

In case of cancer, what types of chemotherapy or other treatments have you had?

 

Are you taking any medication or nutritional supplements? Please describe.

 

Are you taking any amphetamines (Adderall), Benzo (Valium, Xanax), or any antidepressant medications?

 Yes
 NO
 Yes