All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Client Information

feet inches
(in pounds)

PERSONAL HEALTH HISTORY

Have you ever been diagnosed or have any of the following conditions?
Cancer
Carpal Tunnel
Cholesterol Issues
Thyroid Issues
Diabetes
Lung Problems
Immune Problems
Heart Disease
Hypertension
Acid Reflux
Seasonal Allergies
Alzheimer's
Skin Wrinkles
>Muscle Loss
Osteoporosis
Mood Swings
Retina Problems
Homocysteine level elevation
Iron Deficiency / Anemia
Gout
Migraines
Seizures
Multiple Sclerosis
Liver Disease
Arthritis

Surgeries

Other Hospitalizations

Prescription & Over-the-counter Drugs

List your prescribed and over-the-counter drugs, such as vitamins and inhalers:

Coumadin
Warfarin

Allergies to Medications

Allergies to Fruits

Health Habits and Personal Safety

All questions contained in this questionnaire are optional and will be kept strictly confidential.

Exercise

Vitamins & Minerals

Are you currently taking any vitamins or minerals?

Diet

Vegetarian?
High Protein?
Caffeine
Alcohol

Tobacco

Do you use tobacco?
pks/day
#/day
#/day
#/day

Family Health History

Father

Male

Mother

Female

Grandfather Paternal

Male

Grandmother Paternal

Female

Grandfather Maternal

Male

Grandmother Maternal

Female

Mental Health

From Mild to Severe
Is stress a major problem for you?
Do you feel depressed?
Do you have trouble sleeping?

Women Only

Are you menopausal or pre-menopausal?
Are you on birth controll pills?
Heavy periods, irregularity, spotting, pain, or discharge?
Are you pregnant or nursing?
Any problems with control of urination?
Any hot flashes or sweating at night?
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Men Only

Do you usually get up to urinate during the night?
Any loss in libido?
Has the force of your urination decreased?
Do you have any problems emptying your bladder completely?
Any difficulty with erection or ejaculation?

Other Problems

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

Patient's Agreement and Release

THIS AGREEMENT is made and executed on the 27 day of October 2021, between iVitamin Science, Inc. (hereinafter referred to as “iVitamin Science”) and (hereinafter referred to as “Client”).

The Client understands and agrees to the following. That information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration. That iVitamin Science™ supplements are not intended to treat, cure, or prevent any condition or disease. The Client understands and agrees that he/she should consult with their personal physician, or healthcare provider, before starting any diet, exercise, or supplementation program. That iVitamin Science™ supplements may not be appropriate for everyone; you should not take iVitamin Science™ supplements if you are pregnant or nursing.

The Client understands and agrees that he/she should read all product packaging thoroughly, and keep their health care provider informed about any dietary supplements they are taking; that they should consult their physician first if they are taking prescription drugs, or are being treated for any disease or medical condition. The Client understands and agrees that he/she should not exceed the recommended dosage; keep all supplements out of reach of children; and if you have, or suspect you have, a medical problem, contact your health care provider immediately. In addition, The Client understands and agrees that iVitamin Science™ supplements are custom formulated and packaged specifically for them. These compounded supplements cannot be returned or refunded.

I agree.
Date: 10/27/2021