First Name *
Middle Name
Last Name *
Address
State
Zip Code
Referred by
Phone Number
Cell Number
Email Address
Date of Birth (YYYY-MM-DD)
Age
Sex
—Please choose an option—MaleFemale
Place of Birth (City/State/Country)
Allergies to medicine/foods/etc
Where did you spend most of your life growing up?
Insurance Provider Name
Customer Service/Provider Phone Number
Subscriber Number
Group Number
When did you last feel your best? (Year or Age)
What are your main health concerns?
Past Medical History (Please list any hypertension, high cholesterol, thyroid issues, etc.)
Past Surgical History (Please give procedures and dates)
Medications
Supplements
Smoking
NoYes
How much?
Alcohol
Average daily/weekly intake
Recreational Drug Use
Married
Significant Other
Sexually Active
Birth control method (if applicable)
Occupation
How many hours/week
How long
Child 1 - Name
Child 2 - Name
Child 3 - Name
Child 4 - Name
Child 5 - Name
Stress Level
—Please choose an option—Above AverageAverageBelow Average
Most common foods eaten
Most common beverages (include caffeinated drinks)
Exercise and other physical activity (include amount of time)
Father
Mother
Paternal Grandfather
Maternal Grandfather
Paternal Grandmother
Maternal Grandmother
Brothers
Sisters
Paternal Uncles
Maternal Uncles
Paternal Aunts
Maternal Aunts
