Please list your current health issues in order of priority and rank their severity (mild | moderate | severe).
Please list your history of surgeries, from oldest to most recent (include year of surgery).
Please list any allergies that you may have.
If there is other pertinent health information that you would like us to be aware of, please list that here.
Do you exercise regularly? If no, please write NO in the box. If yes, please specify TYPE and DURATION of exercise.
Please specify average hours of sleep / night.
Please specify what time you normally go to bed (most often) and your wake-up time (most often).
How many drinks do you have per week? Please specify and indicate what type of alcoholic beverage your amounts apply to.
Example:
Beer (cans/bottles) ______ (#)
Wine (glasses) ______ (#)
Spirits (shots) _______ (#)
What is your daily coffee intake amount, on average? Please specify. Example: _______ cups / _________ espressos.
Please list other caffeinated beverages that you drink and how often and in what quantity.
Please list your daily water intake in terms of cups.
Example: 5 cups.
Do you currently smoke? If yes, please write YES in the box provided. Please specify how many cigarettes / day. If no, please write NO in the box.
Please list all medications and supplements that you currently take, your dosage, frequency taken, and how long you have been using each.
Example: Aspirin, 2 pills daily, since June, 2015.
Please list the name and a contact number/e-mail of your General Practitioner (GP) and the clinic you visit.