Required fields are marked with an asterisk *. First Name *Last Name *Date of Birth *Have you ever had any of these medical illnesses? (Mark all that apply) Asthma Diabetes Emphysema Bronchitis Pneumonia Alcoholism Heart Disease Anemia High Blood Pressure Liver Disease Hepatitis Gastric Reflux Ulcers Kidney disease/stones/infections Lupus Seizures Stroke or TIA Thyroid Disease Chronic Fatigue Rheumatoid Arthritis Osteoarthritis Osteoporosis PTSD Scoliosis MRSA Infection Shingles Blood Transfusions Insomnia Sleep Apnea FibromyalgiaHave you been diagnosed or treated for blood clots? * Yes NoIf yes, where were your blood clots located?Have you ever had cancer? * Yes NoIf yes, please describe your cancer and treatment.Please list any other medical issues not listed above.Please list any surgeries that you have had in the past:Have you ever had a problem with anesthesia? * Yes NoIf yes, please explain:Have you ever had problems with wounds healing? * Yes NoHave you used any illicit drugs? * Yes NoIf yes, please list the drug(s).Do you use tobacco products? * Yes NoIf yes, how often do you use tobacco products?If yes, please list the tobacco products you use.Family HistoryHas your MOTHER had any serious/chronic illnesses? * Yes NoIf yes, please explain.Has your FATHER had any serious/chronic illnesses? Yes NoIf yes, please explain.Have your SIBLING(S) had any serious/chronic illnesses? * Yes NoIf yes, please explain.Social HistoryAre you: * Single Married Divorced Separated WidowedDo you live: * Alone With spouse/significant other In a care facilityHow many children do you have? *Employment * Homemaker Employed Retired On DisabilityPlease describe your professionHow would you rate your quality of life now from 1 (worst) to 10 (best)? * 1 2 3 4 5 6 7 8 9 10AllergiesPlease list any known allergies to medications.Are you allergic to any of the following? (Mark all that apply) Latex Tape MetalIf you are allergic to metal, please explain below:Current MedicationsPlease list the medications you are currently taking. (Example: Tylenol 650mg 2 times/day as needed for headache) Rate Your Experience Submit Your form has been securely transmitted to the Colorado Chiari Institute! There was an error with the form submission.