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HEALTH HISTORY FORM
First name
Last Name
Organization/Company
Phone
Email
What are your motivators to becoming a Beyond participant?
Reverse diabetes
Reverse chronic disease
Reduce inflammation
Reduce/eliminate medications
Weight loss
Reduce pain
Become healthier/feel better
Make everyday activities and exercise easier
Increase energy
Reduce anxiety and depression
Increase mental clarity
Balance emotional well-being
Improve sleep quality
Live longer
Measurements
Height
Weight
Waist
Medical History
Please check all the health conditions that your doctor has diagnosed.
Gastrointestinal
Irritable bowel syndrome
Inflammatory bowel disease
Crohn's disease
Ulcerative colitis
Celiac disease
Gastric or peptic ulcer disease
GERD/reflux/heartburn
Hepatitis C or liver disease
Other
Cardiovascular
Heart disease/heart attack
Stroke
Elevated cholesterol
Irregular heart rate
High blood pressure
Elevated triglycerides
Other
Musculoskeletal/Pain
Osteoarthritis
Chronic pain
Migraines
Other
Inflammatory/autoimmune
Chronic fatique syndrome
Rheumatoid Arthritis
Lupus SLE
Fibromyalgia
Frequent infections
Severe infectious disease
Herpes
Gout
Other
Please list all prescription and over-the-counter medications you are taking
Not applicable
Blood pressure medications
Cholesterol medications
Insulin
Reflux medications
Sleep aids
Pain medications
Thyroid medications
Depression medications
Anxiety medications
Neurological/brain
Depression
Anxiety
ADD/ADHD
Multiple sclerosis
Seizures
Alzheimer's
Parkinson's disease
Anorexia Nervosa
Bulimia
Unspecified eating disorder
Other
Urinary/Reproductive
Kidney stones
Urinary tract infections
Yeast infections
Prostate Problems
Infertility
Other
Dermatological
Eczema
Psoriasis
Acne
Other
Metabolic/Endocrine
Type 1 disease
Type 2 disease
Metabolic syndrome
Hypoglycemia
Hypothyroidism
Hyperthryroidism
Polycystic ovarian syndrom
Other
Have any of your close relatives, parents, siblings, children or grandparents been diagnosed with the following:
Heart disease
High blood pressure
Stroke
Type 1 diabetes
Type 2 diabetes
Overweight
Food intolerance
Autoimmune disease
Cancer
Allergies
Yes
No
Health Questions
Have you ever asked your physician to help you with your weight and medications?
Yes
No
How many diets have you been on during your life?
0
1-2
3-4
5 or more
Do you engage in physical activity on a regular basis?
Yes
No
In general, how satisfied are you with your life? (include personal and professional aspects)
Very satisfied
Somewhat satisfied
Neither satisfied or dissatisfied
Somewhat dissatisfied
Very dissatisfied
Was your physician successful with reducing your weight and medications?
Yes
No
Not applicable
Do you experience any trouble sleeping?
Trouble falling asleep
Wake up during the night
Don't feel rested
No, I always sleep well
In the past year, how many days of work have you missed due to personal illness?
0
1-2
3-5
6-10
11-15
16 or more
SUBMIT
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