Contact & Health History Information
Patient Name
*
First Name
Last Name
Patient Birth Date
*
Please select a month
January
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Month
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Day
Please select a year
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1924
1923
1922
1921
1920
Year
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
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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 pounds
Lose weight, less than 25 pounds and get in better shape
Need more energy; want to feel better, sleep better, enjoy more activities
Learn more about healthy options, supplements, hydration, avoid illness, age well
Learn more about cosmedic options such as healthy hair, skin care, eyelashes, appearance in general
Learn more about life, health, career, financial, and relationship coaching services available
Other
Your Health & Medical History
Please list any food or drug allergies
*
Do you currently or have you ever had: (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Eating Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Irritable Bowel Syndrome
Chronic diarrhea or constipation
Acute or Chronic Pancreatitis
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Personal or Family History of Medullary Thyroid Cancer
Tuberculosis
Substance Abuse
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
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.
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Please list your Current Medications
*
Healthy & Unhealthy Habits
Exercise
Never
1-2 days per week
3-4 days per week
5+ days per week
Eating following a diet
I have a strict diet
I don't have a diet plan
Alcohol Consumption
I don't drink
1-2 glasses/day
3+ glasses/day
Caffeine Consumption
I don't use caffeine
1-2 cups/day
3+ cups/day
Do you smoke?
No
0-1 pack/day
1+ 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
*
Date
*
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Month
-
Day
Year
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