MIST + 2

Question 1

Have you gained or lost weight in the last year? (amount and why)

Answer 1

Have you gained or lost weight in the last year? (amount and why)

Question 2

How would you rate your overall health? (0-10 VAS)

Answer 2

How would you rate your overall health? (0-10 VAS)

Question 3

Medications

Answer 3

Do you take any medications or supplements?

		i. Over the counter (aspirin, decongestants, vitamins)
		i. Prescription (birth control, blood pressure)
		i. Other Drugs (alcohol, tobacco, recreational drugs)

Question 4

Illnesses

Answer 4

a. Do you currently suffer from any diseases or allergies?
b. Have you suffered from any other significant diseases or allergies in the past?
c. Have you had measles, mumps, chicken pox, or other common childhood illnesses?

Question 5

Surgeries

Answer 5

Have you had any surgeries? (tonsils, appendix, hernia, caesarian)

Question 6

Traumas

Answer 6

Have you had any injuries, accidents, broken bones, bad falls, or blows to the head or body?
b. Do you use any supports, braces, wraps, heel lifts?