Contact & Health History Information Form

Contact & Health History Information
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Contact Phone Number*
Please enter a valid phone number--area code required.
Contact e-mail *
example@example.com
Emergency Contact Name/Relationship*
Name/Relationship
Emergency Contact Phone Number*
Please enter a valid phone number--area code required.
Your Address*

Street Address

Street Address Line 2

CityState

Zip Code
Your Height *
Ft/inches or total inches
Your Weight *
pounds
Your Current BMI
if not certain, may be completed by the provider
Your Health & Wellness Goals:*
State your health & wellness goal in your words.
What is/are your immediate Health & Wellness priorities?

Lose weight, more than 25 poundsLose weight, less than 25 pounds and get in better shapeNeed more energy; want to feel better, sleep better, enjoy more activitiesLearn more about healthy options, supplements, hydration, avoid illness, age wellLearn more about cosmedic options such as healthy hair, skin care, eyelashes, appearance in generalLearn more about life, health, career, financial, and relationship coaching services availableOther
Your Health & Medical History
Please list any food or drug allergies*
Do you currently or have you ever had: (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEating DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsIrritable Bowel SyndromeChronic diarrhea or constipationAcute or Chronic PancreatitisUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsPersonal or Family History of Medullary Thyroid CancerTuberculosisSubstance AbuseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses or health concerns:
Please list any Operations and Dates of Each
Please list any recent diagnostic tests or lab work performed.
Please provide copies of diagnostic tests or lab work performed.

if unable to upload bring copies with you
Cancelof
Please list your Current Medications*
Healthy & Unhealthy Habits
Exercise

Never1-2 days per week3-4 days per week5+ days per week
Eating following a diet

I have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3+ cups/day
Do you smoke?

No0-1 pack/day1+ packs/day
Include other comments regarding your Medical History
Your Primary Care Provider*
**I understand that RED Zone Health & Wellness, LLC does not provide primary care medical services.**
Your Primary Care Provider Phone Number *
Please enter a valid phone number.
Your Pharmacy Name*
Your Pharmacy Phone Number*
Please enter a valid phone number.
Signature*

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Date*

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Date
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Contact & Health History Information

Your Health & Medical History

Healthy & Unhealthy Habits