Patient Application 

Please tell us you personal contact information and medical history. It can take 5 business days to receive a response. We look forward to working with you.

 

Name *
Name
Phone *
Phone
Country Code Example: USA 001
Example:USA 001
Date Of Birth *
Date Of Birth
Please give your height in inches or cms
Please give your weight in pounds or kilos
Referred? *
Treatment Area Of Interest? *
Medical Records Available? *
Special Needs
Need A Wheelchair? *
Trouble Speaking? *
Emergency Contact
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Example: USA 001
Your Physician
Physician Number
Physician Number
Example: USA 001
Medications
Example: Tylonal, Ibuprofen, Lortidine
Subject: Health History
Cancer? *
Diabetic? *
Type of Diabetes?
Epilepsy? *
Poor Vision? *
Muscle Wasting? *
Muscle Spasms? *
Depression? *
Loss Of Memory? *
Headaches? *
Dizziness? *
Sleep Problems? *
Asthma? *
Chronic Bronchitis? *
Emphysema? *
Tuberculosis? *
Myocardial Infarction? *
If Yes, Date Of Myocardial Infarction?
If Yes, Date Of Myocardial Infarction?
Angina Pectoris? *
Bypass Surgery? *
If Yes, Date Of Bypass Surgery?
If Yes, Date Of Bypass Surgery?
Tachycardia? *
High Blood Pressure? *
Low Blood Pressure? *
Leg Cramps? *
Swollen Ankles? *
Ulcers? *
Rapid Weight Gain? *
Rapid Weight Loss? *
Hepatitis? *
Gallbladder Problems? *
Gallstones? *
Sinus Problems? *
Allergies? *
Rheumatoid Arthritis? *
Joint Pain? *
Thyroid Problems? *
If Yes, Is Your Thyroid
Adrenal Gland Dysfunction? *
Menopause? (Women)
Low Testosterone? *
Food Allergy? *
Egg Allergy? *
Allergic to Vaccines? *
Do You Take Human Growth Hormone? *
Do You Take Hormone Therapy? *
PSA Test? (Men)
Mammogram? (Women)
Surgical Procedures? *
Pregnant? *
Lifestyle
Do You Smoke? *
Do You Drink Alcohol? *
Family History
Hypoglycemia? *
Thyroid Problems? *
Cancer? *
Alzheimer's Disease? *
Dementia? *
High Blood Pressure? *
Kidney Problems? *
Heart Problems? *
Arthritis? *
Prostate Problems? *
Mental Disorders? *
Anxiety? *
Lung Problems? *
Stroke? *
I Understand *
I Understand *
I Agree *
I Agree *
I Agree *
Trouble Submitting? Contact info@integrated-health-systems.com