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test-form

    This is to make sure we ask the right questions.


    Date*




    YesNoUnknown

    Have you had any surgery within the last year with General Anesthesia? *
    YesNo

    Do you have any of the following medical problems?

    Irregular Heartbeat *
    YesNo

    Do you take medication to control this condition?

    Coronary Artery Disease:*

    Do you take medication to control this condition?*

    Congestive Heart Failure *


    Depression*

    Stroke*

    Adrenal Hyperplasia *

    Date of last physical *

    Stress Level *

    Have you ever had a scalp biopsy? A scalp biopsy is when a physician removes of a small portion of scalp from the patient’s head which is then sent to a lab for testing. *

    Was a diagnosis made?




    CBC (Complete Blood Count)*

    Hormone: DHEA/Testosterone/Estrogen *

    Thyroid Panel: *

    Glucose: *

    Vitamin D: *

    Was Vitamin D in a normal range? *

    Iron: *

    Was it in a normal range?

    Have you ever been diagnosed with any type of Anemia?






























































    Check all that apply.













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