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Home
Books
Hard Copy Books
Electronic Books
Electronic Recipe Books
Training Plans
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Blog
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Medical Health History
eNRG Performance team member
*
Bob Seebohar
Lauren Mitchell
Elizabeth McNear
John Baker
Marco Hintz
Julie Lyons
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone number
*
(###)
###
####
Date of birth
*
MM
DD
YYYY
List any allergies to medications, plants, animals or foods
*
List any regularly used over the counter or prescription medications
*
List any vitamins, minerals, herbs or other supplements used daily
*
Do you have asthma or exercise induced asthma?
*
Yes
No
Have you ever had a seizure?
*
Yes
No
Have you been diagnosed with any type of diabetes, pre-diabetes, insulin resistance, or do you have a high fasting blood sugar?
*
Yes
No
Are you or have you been anemic?
*
Yes
No
Have you been diagnosed with disordered eating or an eating disorder?
*
Yes
No
If so, please explain
Are you being treated for high blood pressure?
*
Yes
No
Do you have or have you ever had heart disease?
*
Yes
No
To your knowledge, do you have any family history of heart disease, diabetes, stroke, or other chronic disease (in parents)? If so, please explain
*
Yes
No
If yes, please explain.
Do you have any risk factors for metabolic syndrome (large waist circumference, high triglycerides, high blood pressure, low HDL, high fasting blood sugar)?
*
Yes
No
If yes, please list
Do you have or have you ever had kidney disease?
*
Yes
No
If yes, please explain
Do you have or have you ever had liver disease?
*
Yes
No
If yes, please explain
Do you or have you ever had stomach disease (ulcers, bleeding, etc.) or any bowel condition/disease (IBS, IBD, Crohn’s, etc.)?
*
Yes
No
If yes, please explain
Do you or have you ever had frequent headaches?
*
Yes
No
If so, please explain
Do you or have you ever had a hernia?
*
Yes
No
If yes, please explain
Have you ever had a concussion or head injury?
*
Yes
No
If yes, please explain
Have you ever had a broken bone or fracture?
*
Yes
No
If yes, please explain
Have you ever had a shoulder injury?
*
Yes
No
If yes, please explain
Have you ever had a hip or knee injury?
*
Yes
No
If yes, please explain
List any surgeries that you have had
*
Do you wear any removable dental appliances that affects your chewing or swallowing ability?
*
Yes
No
If yes, please list
How often do you have a bowel movement and how would you describe it, generally (loose, watery, solid and formed, floats, etc.)?
*
When was your last blood work testing done?
Describe your sleep patterns. Do you feel that you get enough? Are you rested upon waking? Please share.
Females only
What phase (follicular or luteal) of your menstrual cycle are you currently in or what day of your cycle are you in?
If you are on any form of birth control or taking any hormone replace therapy, please list which type (or brand name) and for how long you’ve been using.
Are you pregnant?
Yes
No
If you are not post-menopausal or on a birth control method that prevents bleeding, how often do you have periods, for what duration, and how heavy is your flow?
If yes, please explain
For all individuals
The above answers have been answered correctly and truthfully to the best of my knowledge
*
Yes
Additional information you would like to share
How did you hear about us?
*
Thank you!
