Please complete the form below. All information collected is strictly confidential.

Name *
Name
Address *
Address
Phone *
Phone
Heart Disease *
Stroke *
High Blood Pressure *
High Blood Cholesterol *
Diabetes *
Colon / Rectal Cancer *
Skin Cancer *
Stomach Cancer *
Breast Cancer *
Prostate Cancer *
Uterine / Edometrial / Cervicale Cancer *
Asthma *
Gout *
Osteroporosis *
Osteo / Rheumatoid Arthritis *
Overweight *
Alcoholism *
Chrohn's Disease *
Diverticulitis *
Ulcerative Colitis *
Recurrent Bronchitis
Anorexia Nervousa / Bulimia *
General Eating Disorder *
Amennoreha *
Stress Disorder *
Mental Illness *
Depression *
Multiple Sclerosis *
Hepatitis *
HIV +/ Aids *
Have you stopped having periods because of menopause? *
Are you currently involved in hormone replacement therapy? *
Have you ever had a Bone Density Test performed? *
If no, are you interested in having a BDT performed?
Has you physician ever told you that you have heart trouble? *
Have you been aware of heart palpitations? *
In the last 3 months have you experienced any pain, pressure or discomfort in your chest? If so, describe the character of the discomfort (check all that apply). *
Sharp, fleeting, localized pain or “catch” *
Intensity changed if you took a deep breath or changed positions *
Dull pressure, ache, tightness, pain or burning *
Radiates to the jaw, arm, neck, shoulder or back *
Predictably brought on by exertion *
Has awakened you from sleep *
Predictably relieved by rest within 10 minutes *
Predictably relieved by nitroglycerine within 10 minutes *
Are troubled with dizziness or near fainting? *
Do you easily become short of breath? *
Do you wake during the night short of breath? *
Do you elevate your head to help you breathe at night? *
Do your ankles swell? *
Do you have leg cramps when walking? *
Has your physician ever told you that you have a heart murmur? *
Has your physician ever told you that you had an abnormal ECG indicating any pathology? *
Have any of your blood relatives died of heart disease before the age of 60 years? *
Have you ever had a heart attack or bypass surgery/angioplasty? *
Are you or have you ever been involved in a cardiac rehab program? *