(Main symptom(s) as title)

Height:

Weight:

Age:

Sex assigned at birth:

Medications:

Simplified Symptoms list:

Health background - history of past illnesses, surgeries, etc.:

Background of Symptoms - Tell the story and background of your symptoms. Things to include: When the symptoms began, what was happening around the time the symptoms started (eg. if you started or stopped any medication, injuries, trips, etc), what makes symptoms better or worse, things doctor have already ruled out, any changes from the initial presentation of the symptoms, etc:

Family history - List of family members and their illnesses (be sure to include if they are maternal or paternal relatives):

Other information- Here you can include your sleep, diet, exercise, or anything else about your life that might be relevant :

Be sure to add photos of redacted labs, imaging studies, or any other medical reports that you have.