Ignite — Medical History

Section 1 of 7

Current conditions

Active diagnoses

Anything you're currently being treated for or living with. One per line — ICD-10 codes optional if you happen to know them.

active_diagnoses

Anything you're concerned about that isn't formally diagnosed? medical_concerns

Section 2 of 7

Medications & allergies

What you're taking now

Everything — including medications prescribed elsewhere, over-the-counter, and supplements. Interactions are the reason we ask.

Current medications One per line: name — dose — how often — how taken — when you started active_medications

Medications you've stopped And roughly when, plus why if you remember medication_history

Allergies & reactions

This one can't be left blank. If you have no known drug allergies, check the box below. An empty allergy field and "no allergies" look identical in a chart, and only one of them is safe.

✓No known drug allergies (NKDA)

Allergies and what happens Drug, food, environmental — and the reaction, not just the allergen patient_allergies

Section 3 of 7

Past medical & surgical history

Past medical history Significant illnesses, hospitalizations, conditions that have resolved past_medical_history

Surgical history What, and roughly when surgical_history

Any surgery planned or being discussed?

Section 4 of 7

Family history

Blood relatives only — parents, siblings, grandparents.

Check anything that runs in your family family_history

✓Heart disease or heart attack

✓Stroke

✓High blood pressure

✓Diabetes

✓Blood clots (DVT or PE)

✓Thyroid disease

✓Breast, prostate, ovarian or uterine cancerHormone-sensitive cancers — relevant if you're considering hormone therapy

✓Medullary thyroid carcinoma or MEN2Relevant to GLP-1 therapy

✓Any other cancer

✓Autoimmune disease

✓Mental health conditions

✓None that I know of

Details — who, and roughly what age

Section 5 of 7

Social history

Tobacco or nicotine social_history

✓Never used

✓Former — quit

✓Current — cigarettes

✓Current — vape or nicotine pouches

Alcoholic drinks per week

Recreational substances

Occupation

Preferred pharmacy Name and location — this is where your prescriptions go preferred_pharmacy

Section 6 of 7

Safety screen

These determine whether a therapy is safe for you. Anything checked here means your provider reviews it before prescribing — that's the point of asking.

Check anything that applies to you

Nothing here rules you out automatically. It routes you to a conversation.

medical_concerns + provider review flag

✓Personal history of medullary thyroid carcinoma, or MEN2

✓History of pancreatitis

✓Gallbladder disease or symptomatic gallstones

✓Gastroparesis or severe reflux

✓Severe gastrointestinal disease

✓Type 1 diabetes, or a history of diabetic ketoacidosis

✓Diabetes of any type

✓History of an eating disorder

✓Personal history of hormone-sensitive cancerProstate, breast, endometrial, ovarian

✓Active or recent cancer of any kind

✓Blood clot — DVT or PE, current or past

✓Stroke or TIA

✓Coronary artery disease, recent heart attack, or uncontrolled cardiovascular disease

✓Polycythemia — thick blood, high hematocrit

✓Untreated sleep apnea

✓Liver disease — hepatitis, cirrhosis, impaired liver function

✓Severe kidney disease

✓Undiagnosed abnormal uterine or vaginal bleeding

✓Migraine with aura

✓Active psychiatric condition, or taking psychotropic / MAOI / serotonergic medication

✓History of a hormone-related psychiatric event

✓Recent or planned surgery, or taking blood thinners

✓G6PD deficiency

✓Known allergy to a hormone, peptide, or GLP-1 preparation

✓None of these apply to me

Your provider will review this before anything is prescribedThat's expected and it isn't a rejection. Add detail below so the review is quick.

Details on anything checked

Section 7 of 7

Reproductive status

Relevant to every therapy we offer. Asked of everyone.

Which applies to you right now?

✓Not applicable

✓Currently pregnant

✓Possibly pregnant

✓Trying to conceive

✓Currently breastfeeding

✓Recently postpartum

✓None of the above

Future fertility plans Some hormone therapies affect fertility. Say so now and your provider can plan around it.

✓I want children in the future

✓I'm not planning to

✓Unsure

✓Prefer not to say

Contraception currently used

Before you submit

I confirm this is honest and complete to the best of my knowledge, and I'll tell Ignite when something changes — a new diagnosis, a new medication, a pregnancy, or a planned surgery.

Your name

Date