General Patient Information Form

General Patient Information Form

General Patient Information

(Should take between 1-2 minutes to complete)
Patient Gender
Patient Name
Patient Birth Date

MonthDayYear
Patient Height
inches
Patient Weight
lbs
Patient E-Mail
Reason for contacting The Drugless Doctor:
Your Health History
Please list any food sensitivities
Have you ever had (Please check all that apply)

Other
Other illnesses:
Please list any Operations and Dates (Year) of Each
Please list your Current Medications & Nutritional Supplements
Healthy & Unhealthy Habits
Exercise
Food & Diet History
Alcohol Consumption
Caffeine Consumption
Do you smoke?
Include other comments regarding your Medical History
Phone Number (Optional)

Area CodePhone Number
Should be Empty: