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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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?

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)
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
Eating following a diet
Alcohol Consumption
Caffeine Consumption
Do you smoke?
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.Format: (000) 000-0000.
Your Pharmacy Name
Your Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Contact & Health History Information

Your Health & Medical History

Healthy & Unhealthy Habits