How do you estimate your overall health:
Have you ever had:
Yes No
1. Hospitalization for injury or illness
2. An allergic reaction to:
- Aspirin, ibuprofen, acetaminophen
- Penicillin
- Erythromycin
- Tetracycline
- Codeine
- Local Anesthesia
- Fluor
- Metals (cobalt, nickel, stainless steel, gold, etc.)
- Latex
- Other drugs
3. Heart problems, heart problems
4. Problems of taste / smell
5. Rheumatic fever
6. Scarlet fever
7. Of high blood pressure
8. Low pressure
9. Stroke (cerebrovascular accident)
10. An artificial prosthesis (valve in the heart, bypass)
11. Anemia or other blood problems
12. Prolonged bleeding
13. Tuberculosis
14. Asthma
15. Sleep disorders or breathing (snoring, sinus)
16. Kidney disease
17. Liver disease
18. Jaundice
19. Thyroid disease or parathyroid
20. Hormone deficiency
21. Cholesterol (hypercholesterolemia)
Have you ever had:
Yes No
22. Diabetes
23. Stomach ulcer or duodenal
24. Digestive problems (acid reflux)
25. Arthritis
26. Glaucoma
27. Contact lenses
28. Injuries to the head or neck
29. Epilepsy or seizures
30. Neurological problems
31. Viral infections and cold sores
32. Lump or swelling in the mouth
33. Hives, hay fever
34. Venereal diseases
35. Hepatitis, what type
36. HIV-AIDS
37. Tumor, abnormal bumps
38. Radiotherapy
39. Chemotherapy
40. Emotional problems
41. Psychiatric treatment
42. Antidepressant medication
43. Alcoholism - Addiction
Are you
Yes No
44. Currently under treatment for another disease
45. Aware of a change in your general health
46. Treated for osteoporosis, osteopenia
47. Often tired or exhausted
48. Subject to frequent headaches
49. A smoker or ex-smoker
50. Often unhappy or depressed
51. WOMAN: Do you take the pill
52. WOMAN: Pregnant
53. MEN: do you have prostate disorders
Make a list of all medications, supplements or vitamins taken in the last two years.

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