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Basic Info

First Name

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Date of Birth (mm/dd/yyyy)

Password

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Personal

Country you are currently located in

For which state do you want a doctor evaluation

Please provide the exact address where you would like to receive your recommendation card.

Address

Apartment

City

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Phone

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Medical

What is/are the main medical problem(s) which you currently have or have had in the past?*:

HIV/AIDSNauseaFibromyalgiaSeizuresArthritisMuscle SpasmMigraine HeadachesAnxietyChronic PainGlaucomaCancerTrouble SleepingLoss of AppetiteWeight LossOther

Are you RENEWING your recommendation (Have you had a recommendation in the last 10 years)*:

Do you currently use specific medications for your medical condition?:

Are you taking any prescription medications or herbs? *:

Do you have any allergies to any medications? *:

Have you ever had any surgeries or been hospitalized?:

Do you exercise?:

Do you smoke tobacco?:

Do you drink alcohol?:

Are there health/medical problems that occur frequently in your family?:

Have you experienced or been diagnosed with any of the following *:

DepressionBipolar DisorderSchizophreniaSuicidal thoughtsADHDNone

Are you pregnant? *:

Breastfeeding?:

Do you have a primary care provider? *:

When was the last time you saw your doctor/specialist about these complaints? (mm/dd/yyyy)

Medical Files

If available, you will have an ability to upload to your portal previous Recommendation or any other medical records as related to the medical condition(s) identified above.

I cannot provide the records because of:

Provide details on the medical condition and diagnosis:

Complete profile

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Fee charged after visit:

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