This Customer Medical Profile needs to be submitted with your first order only, along with the Customer Order Form and Customer Authorization Form. You must complete a new Medical Profile annually or if there is a change to your health or medications listed.
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Name   Phone   Fax   Email
       
Address   City   Province/State   Postal/Zip Code
       
Date of Birth (Month / Day / Year)   Height   Weight   Sex Male Female
It is mandatory to have had a physical examination by a physician in the last 12 months.
Have you had one? Yes No

Do you have drug allergies? Yes No
If yes, please enter all the drug(s) to which you are allergic below:
1.   2.   3.  

Check box after medication if you have not taken this medication for at least 30 days.
1. 2.   3.  
4. 5.   6.  
7. 8.   9.  

Our physicians and pharmacists use this summary of your medical history to help serve you better. Please check all conditions that apply to you.
Alcoholism Cholesterol disorder Kidney disorders Smoking
Alzheimer’s Depression Liver disease Stroke
Anemia Diabetes Lupus Surgery
Asthma Emphysema Migraine headaches Thyroid disease
Blood disorders Fluid retention Nutrition deficiency Ulcers
Bone or joint disorders Glaucoma Parkinson’s disease    
Cancer Heart disease Regular exercise    
  Type:     High blood pressure Rheumatoid arthritis    
I hereby confirm that the above information is true and accurate as of the date hereof.
   
Patient Signature   Date