Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

Age, Height, Weight

Have there been any recent weight changes?

Current Health Issues

HEALTH HISTORY

Accidents or Injuries

Serious Illnesses

Chronic Illnesses

Hospitalizations

Operations

Allergies

Current Medications

Nutritional Issues

HABITS

Tobacco

How many packs a day, or if you use chewing tobacco.

Alcohol

Example: I have a glass of wine after dinner.

Street Drugs

Sugar

Example: I drink four cans of soda a day.

Coffee

Please say how many cups of coffee and the approximate size. Example: Four cups a day, size about 16oz(medium/Grande)

Have you ever worked or been exposed to health hazards?

Asbestos, inhalants, chemicals, or radiation? Please explain in detail below.

Have you been in the military?

If Yes, please say how many years.

Typical diet (What foods do you regularly eat?)