Health History Form

In order to provide your healthcare provider with the most complete and individualized therapeutic recommendations, please complete the following form including:

  • Menstrual and Reproductive History (Females Only)
  • Medical History
  • Lifestyle
  • Current Medications
  • Current Symptoms

Please answer all the questions as completely as you can.  This information is released only to your healthcare provider who ordered your testing and all HIPAA confidentiality guidlines are observed.


Restore Health Pharmacy 1289 Deming Way | Madison, WI 53717 | T: 800-558-7046 | F: 888-898-7412 | Email: | RESTOREHC.COM

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