Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home *

Country

(###)

###

####

Cell *

Country

(###)

###

####

Work

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Do you have any medical records? *

Yes

No

Can you provide medical records? *

Yes

No

Have you had any weight gain or loss in the past year? *

Yes

No

Do you smoke? *

Yes

No

Does anyone in the household smoke? *

Yes

No

Any family history of: *

Angina

Asthma

Cancer

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Mental Illness

Seizures

NONE OF THE ABOVE

Any neurological problems: *

Difficulty Speech

Epilepsy

Hand Trembling

Loss of Memory

Loss of Sensation

Paralysis

Seizure

Tingling

Weak Grip

NONE OF THE ABOVE

Any mental or emotional problems: *

Anger

Anxiety/panic attacks

Concentration/focus Problem

Control issues

Depression

Difficulty socializing

Fears

Insomnia

Low self esteem

NONE OF THE ABOVE

Any musculoskeletal problem: *

Muscle Cramps

Muscle Pain

Muscle Twitching

Muscle Weakness

Joint Pain

Joint Stiffness

NONE OF THE ABOVE

Any general conditions: *

Anemia

Bruise easily

Eye Surgery

High blood pressure

Latex allergies

Pregnant

Shortness of breath

Skin problems

TMJ

NONE OF THE ABOVE

Any other complaints: *

Dizziness

Fainting

Fatigue

Lightheadedness

Night sweats

Numbness

Temperature intolerance

Vertigo

Weakness

NONE OF THE ABOVE