BIO-KINETIC CLINICAL APPLICATIONS 1816-1820 W. Mt. Vernon Springfield, MO. 65802 (417) 831-2048 (417) 831-0778 FAX YOUR FULL LEGAL NAME – AS IT APPEARS ON YOUR SOCIAL SECURITY CARD First Name________________________ MI____ Last Name______________________ Race______________ Hispanic Ethnicity: Yes No Social Security #______-____-______ Date of Birth_____ - _____ - ______ Height____ft. ____in. Weight______ (lbs.) Street Address_______________________________ Rm/Apt._________ City_______________________________ State___________ Zip Code______________________ Current Phone #______-______-_________ Alternate Daytime #______-______-________ Last Blood Donation____-____-____ Last Plasma Donation____-____-____ Email address_________________________________________________________________________ What is your gender Male Female Women Only: Method of birth control: _______________________ Last menstrual cycle date: _____-_____-_____ Cycle Length (# of days): _____ Menses Length (# of days): _____ Are you pregnant _____ Plan to become pregnant _____ Nursing or breastfeeding _____ Are you a vegetarian Yes No Are there any foods you cannot or will not eat due to allergies or religious reasons Yes No If yes, please list the food(s): ______________________________ No. of alcoholic drinks _____ (average) Circle One: daily weekly monthly yearly Do you currently use any tobacco products Yes No If no, have you always been a non-tobacco user Yes No If you currently use tobacco (or have in the past), what type ___________ And how much ________ Circle One: daily weekly monthly yearly (i.e., 1/2 pack of cigarettes, 1 can of chew, 2 cigars, 1 pipe, etc.) Month/year started____/________ Month/year stopped____/________ Please circle the type of study you would be interested in. Long term Weekends Out patient Any How were you referred to Bio-Kinetic (name of person or advertisement) _____________________________ Medical History Question List This questionnaire pertains to your entire medical history from the time you were born until now. Please read this carefully and be as thorough as possible. Remember to give details, details, details, such as start and stop dates, diagnosis dates (if diagnosed), allergic reactions and the cause of the reaction, right or left side, how many, etc…. Be specific with your dates, or list the approximate date – month and/or year, if known. Update your medical history when changes occur in the future. If you list any surgeries, please list the condition that led up to the surgery. If you list any medications, please list the reason for which you are taking them. List any previous surgeries or hospitalizations and the conditions that led up to them (include dates). (Please include surgeries such as teeth extractions, surgical sterilization, appendectomy, etc.) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List any food (i.e., peanuts, tomatoes, etc.) drug (i.e., aspirin, Penicillin, etc.) or environmental allergies (i.e., latex, pollen, pet dander, etc.) and the reaction you had to each along with the severity of the reaction. Include the dates of your first and last reaction and whether the allergy was physician diagnosed and/or treated. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List all broken bones with dates. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List any current medications, including over-the-counter products (i.e., vitamins or herbals, etc.). List the date you started them, the reason why and the dosage and frequency (i.e., Prozac for depression, 40 mg, once a day). If you have been vaccinated for Hepatitis B, please also include the dates you received each injection (series of 3). ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Check any conditions that apply to you (past or present). Please list diagnosis/start dates and stop/end dates, if applicable. Cardiovascular (Heart)/Circulatory Chest pains __________________________ High blood pressure ________________________ Heart attack __________________________ Heart murmur _____________________________ Mitral valve prolapse ___________________ Heart palpitations __________________________ Blood disorder ________________________ Heart arrhythmia ___________________________ Anemia ______________________________ Stroke ____________________________________ Blood clots ___________________________ High cholesterol ____________________________ Integumentary (Skin) Eczema ______________________________ Psoriasis __________________________________ Rosacea _____________________________ Atopic Dermatitis ___________________________ Endocrine Thyroid disease _________________________ Diabetes ___________________________________ Hypoglycemia _________________________ Pancreatitis _________________________________ Parathyroid disease ______________________ Adrenal disorders ____________________________ Polycystic ovarian syndrome ______________ Hashimotos disease __________________________ Eyes, Ears, Nose and Throat Hearing impairment _____________________ Cataracts ___________________________________ Glaucoma _____________________________ Deviated septum _____________________________ Sleep apnea ___________________________ Recurrent ear infections ________________________ Recurrent throat infections (strep or tonsillitis) _____________________________ Gastrointestinal Frequent vomiting ______________________ Ulcers _____________________________________ GERD (acid reflux) _____________________ IBS/spastic colon ____________________________ Diverticulosis __________________________ Bowel obstruction ____________________________ Crohn’s disease ________________________ Ulcerative colitis _____________________________ Celiac disease __________________________ Diarrhea ____________________________________ Constipation ___________________________ Hepatic Liver disease __________________________ Jaundice ____________________________________ Hepatitis (+ test) _______________________ Cirrhosis ____________________________________ Gilbert’s syndrome _____________________ Gallbladder disease ____________________________ Genitourinary Abnormal pap smear ____________________ Enlarged prostate _____________________________ Kidney stones __________________________ Prolapsed uterus ______________________________ Kidney disease _________________________ Fibroid tumors _______________________________ Overactive bladder ______________________ Hemorrhoids _________________________________ Frequent urinary tract infections____________ Ovarian cysts ________________________________ Immune/ Systemic HIV (+ test) ____________________________ Lyme disease ________________________________ Polio __________________________________ Lupus ______________________________________ Rheumatic fever _________________________ Meningitis ___________________________________ Rheumatoid arthritis ______________________ Musculoskeletal Arthritis _______________________________ Osteoporosis _________________________________ Fibromyalgia ___________________________ Tremors _____________________________________ Gout__________________________________ Tendonitis __________________________________ Carpal tunnel __________________________ Bunions ____________________________________ Herniated discs _________________________ Torn ligaments/tendons ________________________ Neurological Migraines ______________________________ Concussion __________________________________ Frequent headaches ______________________ Dizziness ____________________________________ Head trauma ____________________________ Loss of consciousness __________________________ Epilepsy _______________________________ Seizures _____________________________________ Fainting _______________________________ ADD/ADHD _________________________________ Multiple sclerosis ________________________ Psychological Anorexia ______________________________ Obsessive compulsive disorder ___________________ Depression _____________________________ Anxiety ______________________________________ Bipolar disorder _________________________ Alcohol abuse _________________________________ Drug abuse _____________________________ Bulimia ______________________________________ Respiratory Asthma ________________________________ Emphysema ___________________________________ COPD _________________________________ TB (+ test) ____________________________________ Miscellaneous/Other Cancer ________________________________ Coma ________________________________________ Tumors _______________________________ Significant visible scars__________________________ Cysts _________________________________ Insomnia _____________________________________ Other (list) ______________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ I confirm that the information provided on this application is, to the best of my knowledge, complete and accurate. _________________________________________ __________________ Participant Signature Date Participant Initials: ____________ PARTICIPANT APPLICATION IRB approval: 01/21/2008 Page 1 of 4