Medical Condition Medical History FormPlease answer the following questions to the best of your ability. This information is confidential and will help us provide you with the best possible care.Do any of the following apply to you? Please select any conditions that apply to you. This helps us ensure your safety and eligibility. None of the below Currently or possibly pregnant, or actively trying to become pregnant Breastfeeding or bottle-feeding with breastmilk End-stage kidney disease (on or about to be on dialysis) Type 1 diabetes Type 2 diabetes on insulin Current or prior eating disorder (anorexia/bulimia) Current suicidal thoughts and/or prior suicidal attempt Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years) History of organ transplant on anti-rejection medication Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)BackNext
