Medical History Survey -

Name *

First

Last

Date of Birth *

Gender *

Level of Education *

Employment Status *

What is your current or previous occupation? *

In the last 5 years what was your highest weight? *

In the last 5 years what was your lowest weight? *

What is your current weight? *

What is your desired weight? *

What is your height in inches without shoes? *

Select any of the following health problems found in your immediate family (parents, sister, brother) *

Do you have any of the following conditions? Mark all that apply. *

What medication are you currently taking? *

Enter N/A if none