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

 

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

 

Marital Status

 

Religion

 

Person to contact in case of emergency

 

Phone number contact person

Relationship with contact person

 

What is your primary language?

 

Do you require translation in order to communicate in English?

Yes
No

Do you have a life insurance policy?

Yes
No

How did you hear about Sanoviv?

Online Search
Friend or Relative
Doctor Referral
USANA
In a Lecture
In a Book or Magazine
Other

What do you want to achieve at Sanoviv?

 

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 are your symptoms and/or diagnosis?

 

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?

 

Have you ever been hospitalized for mental/emotional problems?

Yes
No

Do you have any sensitivities or allergies to food or 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.