Do you have any known drug allergies?
Yes
No
-
If yes, please list in the box provided:
Have you ever been treated for allergies?
Yes
No
-
If yes, please list in the box provided:
Yes
No
-
If yes, please list:
Do you use tobacco products?
yes
no
-
If yes, please quantify type of product and usage:
Do you consume alcohol?
No
Yes
-
If yes, please quantify type of product and usage:
Do you currently follow a routine exercise program?
Yes
No
-
If yes, please quantify type and amount of exercise:
Do
you have any of the following medical conditions?
Medical
Definitions
Do
you have any of the above medical conditions?
Yes
No
-
If yes,
please explain:
Do you have a history of any other medical condition?
Yes
No
-
If yes, please explain:
Have you had any surgeries in the past five (5) years?
Yes
No
-
If yes please explain:
Are you currently pregnant or nursing?
Yes
No
-
If yes, please explain:
Do you have a history of narrow-angled glaucoma?
Yes
No
-
If yes, please explain:
Do you have high blood pressure?
Yes
No
-
If yes, please explain:
Do you have a history of coronary artery disease?
Yes
No
-
If yes, please explain:
Have you ever had a heart attack?
Yes
No
-
If yes, please explain:
Do you have a history of kidney or liver disease?
Yes
No
-
If yes, please explain:
Do you have asthma?
Yes
No
-
If yes, please explain:
Do you suffer from year round or seasonal allergies with the associated symptoms including: runny and/or
itchy nose, watery or itchy eyes, sneezing, sinus congestion and/or hives?
Yes
No
-
If yes, please explain:
Are you currently taking a momanine oxidase (MAO) inhibitor?
Yes
No
-
If yes, please explain:
