Patient Information

Affiliate #

Form #2

License #32599 Toll Free Phone 1-800-640-2221 7 - 2 Donald Street Winnipeg, MB Canada R3L 0K5 Toll Free Fax 1-800-640-5553 www.cantrustrx.com

Please answer the following questions by circling Yes or No

We will provide your order with child resistant containers unless you request otherwise. Do you refuse to have your medication shipped in child proof containers?	Yes	No
Some drug manufacturers prepackage medication in blister packaging. Do you require us to transfer those medications to a Child Proof Container?	Yes	No
It is mandatory to have had a physical exam in the last 12 months. Have you had one?	Yes	No

Personal Medical History:

Cancer	Y __N	Liver disease	Y __N
Immune disorders	Y __N	Anxiety	Y __N
Poor wound healing	Y __N	Depression	Y __N
Lung disorders (Asthma,COPD,Emphysema)	Y __N	Other emotional disorders	Y __N
Upper respiratory disorders	Y __N	Parkinsons	Y __N
Smoker	Y __N	Epilepsy	Y __N
High blood pressure	Y __N	Schizophrenia	Y __N
Heart disease (incl. Arteriosclorosis, angina heart failure, or history of heart attack)	Y __N	Other neurological disorders	Y __N
Hyperlipidemia (high cholesterol)	Y __N	Thyroid disorder	Y __N
Glaucoma	Y __N	Diabetes	Y __N
Known nutritional deficiency (incl. Minerals or electrolytes)	Y __N	Other endocrine disorders	Y __N
Chemical dependency	Y __N	Recent surgery	Y __N
Rheumatoid Arthritis, Lupus, or connective tissue diseases	Y __N	Past surgery	Y __N
Orthopedic or muscle disorder (incl. fracture, joint disorder, or Carpal tunnel syndrome)	Y __N	Renal or kidney disease	Y __N
Blood disorders	Y __N	Other illness not listed above	Y __N

If you answered yes to any of the above questions, please explain further:

Patient Signature:___________________________________ Date:____________________