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)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaOther
Other illnesses:
Please list any Operations and Dates (Year) of Each
Please list your Current Medications & Nutritional Supplements*
Healthy & Unhealthy Habits
Exercise*

Never1-2 days3-4 days5+ days
Food & Diet History*

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

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History*
Phone Number (Optional)

Area CodePhone Number
Should be Empty:

General Patient Information