New Patient Questionnaire

Date *

- Month - Day Year
Full Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Genetic Background *

African American Native American Mediterranean Hispanic Caucasian Northern European Asian

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone *

- Area Code Phone Number
Secondary Phone

- Area Code Phone Number
E-mail *
Gender
Height
Weight
Relationship status
Email
Whom may we thank for your referral *

Physical Activity
Do you engage in moderate cardiovascular physical activity for a minumum duration of 20 minutes at least 3 days a week? For example: brisk walking, jogging, cardio exercise classes *

Please indicate the type of exercise you are currently engaging in. *

	Type/Intensity (low/mod/high)	# Day Per Week	Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other

Note any problems that limit your physical activity: *

Should be Empty: