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Contact Information |
Additional Information |
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| Your Full Name (please print clearly) |
___________________ | Age | _____________________ | |
| Date | ___________________ | Height | _____________________ | |
| Address | ___________________ | Weight | _____________________ | |
| City | ___________________ | Sex |
M______ F_______ |
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| ___________________ | D.O.B |
D ___ M ___ Y___ |
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| Phone (Home) | ___________________ | Occupation (Optional) | _____________________ | |
| Phone (Work | ___________________ | Retired | _____________________ | |
| State | ___________________ | Referral Source (Optional) | _____________________ | |
| Zip | ___________________ | |||
| Primary Physician Name |
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| Address | _______________________________________________ | |||
| Phone | ___________________ | |||
Regular Exercise Y ___ N___
If yes, what type, frequency and duration. Please indicate in the box below.
If you have previously filled out a questionnaire,
please indicate if there are any changes Y___ N___ First Questionnaire _____
Important
Please note: It is mandatory to have had a
physical examination in the last 12 months
to apply for a consultation.
Have you had one? Yes ________ No _________
Please note: Will you accept a generic version of
the drug drug ordered to save more money?
Please select one: Yes ________ No _________
Please Note: We do not usually ship medications
in Child-Proof Containers. If you require Child-Proof
Containers, please indicate by checking the box. 
Ship in Child Proof Containers
Prescription Requested
Please tell us the medication(s) you are requesting canadameds.com to fill, the dosage, (tablet size) and frequency (how often).
Patient Family History
| 1) Diabetes, thyroid or other endocrine disorder |
Y ___ N ___ |
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| 2) Breast cancer | Y ___ N ___ | |
| 3) Hypertension (high blood pressure) | Y ___ N ___ | |
| 4) Cardiovascular (heart or artery disease) |
Y ___ N ___ | |
| 5) Lipid (cholesterol) disorder | Y ___ N ___ | |
| 6) Prostate Cancer | Y ___ N ___ | |
| 7) Other forms of cancer | Y ___ N ___ | |
| 8) Migraine Headaches | Y ___ N ___ | |
| 9) Other illness not previously noted | |
Patient Medical History
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1) Blood disorders |
Y ___ N ___ | 14) Heart disease including atherosclerosis, angina, heart failure or history of heart attack |
Y ___ N ___ |
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| 2) Cancer | Y ___ N ___ | 15) Renal or kidney disease | Y ___ N ___ | ||
| 3) Immune disorders | Y ___ N ___ | 16) Liver disease | Y ___ N ___ | ||
| 4) Poor wound healing | Y ___ N ___ | 17) Drug allergies | Y ___ N ___ | ||
| 5) Edema or excessive fluid retention | Y ___ N ___ | 18) Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome |
Y ___ N ___ | ||
| 6) Neurological disorders | Y ___ N ___ | 19) Emotional disorders | Y ___ N ___ | ||
| 7) Thyroid, diabetes or other endocrine disorder, including insulin resistance |
Y ___ N ___ | 20) Surgery | Y ___ N ___ | ||
| 8) Any know nutrition deficiency including minerals and electrolytes |
Y ___ N ___ | 21) Glaucoma | Y ___ N ___ | ||
| 9) Hyperlipidemia (high cholesterol) | Y ___ N ___ | 22) Chemical dependency | Y ___ N ___ | ||
| 10 Upper respiratory disorders | Y ___ N ___ | 23) Other illness not yet noted | Y ___ N ___ | ||
| 11) Smoker | Y ___ N ___ | 24) Medications used in the last 12 months |
Y ___ N ___ | ||
| 12) Lung disorder (i.e., asthma, emphysema) |
Y ___ N ___ | 25) Rheumatoid arthritis, lupus, or connective tissue diseases |
Y ___ N ___ | ||
| 13) High blood pressure | Y ___ N ___ |
If you answered yes to any of the above questions please elaborate in the box below (i.e, duration of illness, any treatment or surgery received, amount smoked and for how long.) Please list all medications you are currently using, including the dosage and frequency.
Credit Card Information
| Card Holder Name (on card) |
________________________________________ |
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| Card Holder Address |
________________________________________ |
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| Card Holder City |
________________________________________ |
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| Card Holder State/Province |
________________________________________ |
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| Card Holder Zip/Postal |
________________________________________ |
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| Card Holder Country |
________________________________________ |
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| Credit Card Type |
American Express ___ MasterCard ___ Visa ___ |
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| Credit Card Number |
________________________________________ |
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| Credit Card Expiry | Month ________ | Year ________ |
Patient's Signature ___________________________ Date _________________
Please note, ALL individual pages printed from YOUR printer
must be signed and dated, including the canadameds disclaimer.