Generic Pharmacy c/o CanTrustRx Inc. | #7 - 2 Donald Street, Winnipeg, MB, Canada R3L 0K5| Phone 1:800-640-2221 | Fax: 1-800-640-5553
Generic Pharmacy
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Form 2- MY PERSONAL MEDICAL HISTORY |
* I have been diagnosed or treated for the following conditions:
Medical Condition |
No |
Yes |
Description |
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Drug Allergies |
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Cancer |
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Immune Disorders |
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Poor wound healing |
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Neurological disorders |
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Diabetes, thyroid or other endocrine disorders |
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Known nutrition deficiency including minerals or electrolytes |
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Lipid or cholesterol disorder |
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Heart disease including arteriosclerosis, angina, heart failure or history or heart attack |
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Renal or kidney disease |
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Liver disease |
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Blood Disorders |
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Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome |
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Emotional disorders |
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Surgery |
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Glaucoma |
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Hyperlipidemia (high cholesterol) |
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Chemical dependency |
. |
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Upper respiratory disorders |
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Smoker |
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Lung disorder (i.e. asthma, emphysema) |
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Rheumatoid arthritis, lupus, or connective tissue diseases |
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High blood pressure |
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Other illness not listed above |
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Patient Signature: ____________________________________________