Full Name

Date of Birth

Gender

MaleFemaleOther

Address

City/State/Zip

Phone Number

Email Address

Insurance Provider

Policy Number

Group Number

Do you have any known allergies? If yes, please specify:

YesNo

Do you have any chronic conditions? If yes, please specify:

YesNo

List any current medications, supplements, or treatments:

Have you had any surgeries or hospitalizations in the past? If yes, please provide details:

YesNo

Do you have a family history of any significant medical conditions (e.g., cancer, heart disease, mental health disorders)? If yes, please provide details:

YesNo

Do you use tobacco, alcohol, or recreational drugs? If yes, please provide details:

YesNo

Are you experiencing any of the following? (Check all that apply):

FatiguePainDifficulty SleepingStressDigestive IssuesOther

How would you describe your diet? (e.g., vegetarian, balanced, high-fat)

How often do you exercise?

DailyWeeklyRarely

How many hours of sleep do you get on average?

Less than 55-77+

Do you experience frequent stress or anxiety?

YesNo