Part 1. Contact
Full Name
*
First Name
Last Name
Cellphone Number
*
Mobile
E-mail
*
example@example.com
Emergency Contact Person
Part 2. Personal Measurements
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height in
Weight lb
Pulse
Respirations
Blood Pressure
Sex
Male
Female
Are you active on a daily basis?
*
Yes
No
Part 4. Medical History
Have you ever suffered from...?
Asthma
High or Low Blood Pressure
Epilepsy
Diabetes
Frequent Colds
Dizziness or Fainting
Heart Disease
Shortness of breath
High Cholesterol
Headaches or Migraines
NONE
Have any of your first degree relatives experienced the following conditions?
Heart Attack
High Cholesterol
High Blood Pressure
Congenital Heart Disease
Diabetes
NONE
Do you have any injuries?
Yes
No
How would you rate your current physical fitness?
Poor
1
2
3
4
5
6
7
8
9
Athlete
10
1 is Poor, 10 is Athlete
Part 6. Your Nutrition Habbits
How would you describe your nutritional habits?
Bad
Good
Optimal
Have you ever suffered from any of the following?
Digestive Problems (IBS, Bloating etc)
Allergies
Kidney Problems
Food Intolerances
NONE
Part 7. Screening Results
HGBA1C
Cholesterol
Glucose
Signature
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