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Stush-Medical-Form
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Stush Form
Patient Sign-up
Name
*
Name
First
First
Middle
Middle
Last
Last
Date of Birth
*
Gender
*
Male
Female
N/A
Phone Number
*
Email Address
*
Emergency Contact
Emergency Contact Name
*
Emergency Contact Name
First
First
Last
Last
Relationship to Patient
*
Mother
Father
Guardian
Sister/Brother
Partner
Emergency Contact Number
*
Choose Service
Check the symptoms that you’ re currently experiencing:
Immunity
Recovery & Performance
Inner Beauty
Alleviate
Reboot
Myers Cocktail
Fever
Nicotinamide Adenine Dinucleotide
Slow IV push or with IV hydration
Glutathione with Vitamin C: Slow IV push or with IV hydration
Glutathione NutriBooster Shot
CoQ10
Vitamin B12 (Hydroxocobalamin)
Super B (Olympi’a Vita-Complex)-
Biotin
Vitamin D
Weight Loss
Vitmain C brighter, glowing complexion
Vitmain C brighter, glowing complexion
Slimboost
Are you currently taking any medications?
*
No
Yes
Yes
Do you have any known medical allergies?
*
No
Yes
Yes
Are you currently under medical treatment?
*
No
Yes
Yes
Have you been admitted to hospital or had surgery within the last 2 years?
*
No
Yes
Do you use any kind of tobacco or have you ever used them?
*
No
Yes
Yes
Do you use any kind of illegal drugs or have you ever used them?
*
No
Yes
Yes
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Family History
Check the conditions that apply to you or any member of your immediate family:
Asthma
Cancer
Cardiac Disease
Diabetes
Epilepsy
Hypertension
Lung Problems
Psychiatric Disorder
Seizure Disorder
Stroke
Other
Other
Submit
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If you are human, leave this field blank.
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