Home Medical history form. ayyappadigitalyogastudio -November 29, 2023 0 Medical History Form Full Name First NameLast Name What is your gender? Please Select Male Female N/A Email Address example@example.com Check the conditions that apply to you or any member of your immediate relatives: AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther Check the symptoms that you' re currently experiencing: Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther Are you currently taking any medication? YesNo Please list them. Please list them. Do you have any medication allergies? YesNoNot Sure Do you use any kind of tobacco or have you ever used them? Please Select Yes No What kind of tobacco products? How long have you used/been using them? Do you use any kind of illegal drugs or have you ever used them? Please Select Yes No What kind of drugs? How long have you used/been using them? How often do you consume alcohol? DailyWeeklyMonthlyOccasionallyNever SubmitSubmit Should be Empty: Facebook Twitter
