MEDICATION LIST AND SUPPLEMENTS

PLEASE LIST ANY MEDICATIONS OR SUPPLEMENTS. IF NOT AVAILABLE, PREPARE FOR YOUR MEDICAL EVALUATION WITH OUR MEDICAL TEAM TO GO THROUGH THEM.

MEDICAL HISTORY *

PLEASE CHECK THE AREAS THAT APPLY TO YOU

CARDIOVASCULAR

• Chest painYesNo
• History of heart attack YesNo
• If yes, when and treatment
• History of Angina YesNo
• History of venous or arterial insufficiency YesNo

NEUROLOGICAL

• History of Chronic headaches or migrainesYesNo
• Family history of dementia (including Alzheimer’s) YesNo
• History of memory deficits YesNo
• Poor sleep pattern YesNo
• Numbness in hands, arms or legs(if applicable)YesNo

GASTROINTESTINAL

• History of poor dietYesNo
• History of probiotic useYesNo
• History of inflammatory bowel diseaseYesNo
• 2 or less bowel movements per weekYesNo

ALLERGIES & OTHERS

• Food allergiesYesNo
• Medication allergiesYesNo
• Anesthesia reactionsYesNo
• If yes to any, please describe.
• History of any type of CANCER during the last 5 yearsYesNo
• If yes, please describe type and treatment.
• History of stem cell therapies within 3 years outside of Fountain servicesYesNo
• If yes, please describe time and type of stem cells and therapeutic route.

MUSCULOSKELETON

• History of joint painYesNo
• History of muscle achesYesNo
• History of orthopedic procedures or surgeries?YesNo
• If yes, please describe.
• Are you an athlete or a perform high stress physical activity?YesNo