Medical Approval Personal InformationName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*SelectMaleFemaleContact DetailsEmail* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical History1. Do you have a known allergy or history of any adverse events to any of the below listed medications?*Select all that apply. Benadryl (Diphenhydramine or any other Anti-Histamines) Prednisone (Cortico-Steroid) Penicillin or any derivative of Penicillin such as Augmentin/Ampicillin/Amoxicillin Quinolone Antibiotics such as Ciprofloxin (Cipro/Levaquin) Sulfa Drugs (including Bactrim DS/Septra DS) Cephalosporin such as Keflex/Suprax Hydrocodone or any other Opiate derived drugs (Vicodin/Norco/Codeine/Oxycodone) Lomotil (Diphenoxylate/Atropine) Benzodiazepine class or type of drugs (Xanax/Ambien/Valium/Restoril/Lorazepam) Zantac/Tagamet/Pepcid Symmetrel/Amantadine or other anti-viral drugs such as Tamiflu or Flumadine Zofran (Ondansetron) Guaifenesin (cough medicines) Azithromycin (Z-Pak/Erythromycin/Biaxin) Pyridium (Phenazopyridine) No know allergies to the medications listed above Please list explanation of effects below:* 2. Do you have any known allergies or adverse reactions to ANY medications in the past?*(e.g. rashes, itches, breathing issues, etc.)SelectYesNoPlease list below with explanation of effects* 3. Are you currently taking any regularly prescribed medicines?*SelectYesNoPlease list below* 4. Are you currently taking any medications that help with sleep/mood/depression/anxiety/etc. issues?*SelectYesNoPlease list below* 5. List any regularly used non-prescriptive medications.*(over-the-counter, herbal, homeopathic, vitamins, etc.) If none, please enter None. 6. Are you currently under the care of a physician for any ongoing medical condition?*SelectYesNoPhysician's Name*Physician's Phone7. Have you ever been diagnosed with any of the following medical conditions?*Select all that apply. Anemia Asthma Blood Clotting Problems Cancer Depression Diabetes Ear Infections (Chronic) Epilepsy/Seizures Eye Problems G6PD Deficiency Gout Hearing Problems Heart Disease High Blood Pressure High Cholesterol Hormone Problems Immune System Deficiency Kidney Disease Liver Disease/Hepatitis Lung Disease Prostate Problems Psoriasis/Other Skin Problems Psychiatric Problems Sickle Cell Disease Stomach Ulcer Stroke Thyroid Problems None of the above 8. Are you sensitive to sun exposure?*SelectYesNo9. Would you like us to notify your primary care physician?*SelectYesNoPhysician's Name*Physician's Phone*PhoneThis field is for validation purposes and should be left unchanged.
