Energy Inspired Wellness

The Medical History only needs to be completed once a year or if there are significant changes.

If you have already completed this form click the button to skip.

Medical History

First Name *

Last Name *

Email *

Gender *

Date of birth *

Do you have any known allergies *

Are you taking any medications? *

Are you experiencing any shortness of breath? *

Yes

No

Sometimes

Have you recently or are you currently experiencing any bleeding? *

Yes

No

Have you recently or are currently experiencing chest pain? *

Yes

No

Have you recently or are you currently experiencing any edema or swelling? *

Yes

No

Please place a check if you have any of the following conditions:

Are you taking or have you been told you need to take Digoxin? *

Yes

No

Have you been told you have a decreased GFR or kidney problem? *

Yes

No

Could you be pregnant? *

Yes

No

Are you breast feeding? *

Yes

No

Do you have any medical concerns today?

Client Signature on Medical History *

Medical History Date Signed *