Today's Date
First Name
Last Name
Day Phone
Email
Date of Birth	Month... January February March April May June July August September October November December Day... 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Gender	Select one... Female Male
General Health	Select one... Excellent Good Fair Poor
Please list any Medical Allergies
List all the medications you are presently taking. Please include hormones, vitamins and birth control pills.
Do you suffer from any of the following? Anemia Yes No Hepatitis Yes No Heart Problems Yes No HIV Yes No A Heart Attack Yes No Diabetes Yes No Irregular Beats Yes No Varicose Veins Yes No High Blood Pressure Yes No Psychiatric Treatment Yes No Chest Pain (Angina) Yes No Cortisone Treatment Yes No Abnormal EKG Yes No Drink Alcohol Beverages? Yes No Rheumatic Heart Disease Yes No If yes, how much per week? Lungs Yes No Do you Smoke? Yes No Shortness of Breath Yes No If yes, how much per day? Asthma Yes No Use Illicit Drugs? Yes No Bronchitis Yes No If yes, please specify Emphysema Yes No Exercise Regularly? Yes No Liver Problems Yes No Eye Problems? Yes No Cancer Yes No Kidney Problems? Yes No Do you have a family with history of heart trouble? Yes No Other?
Have you ever been hospitalized? Yes No (If yes, please explain below)
Have you ever had any surgery performed? Yes No If yes, was anesthesia used in your surgery? Yes No (please list dates of any surgeries along with explaining any complications below)
Have you ever been seriously ill in the past year? Yes No (If yes, please explain below)
If you are a female, please answer these questions: Are you pregnant? Yes No Have you been pregnant? Yes No

Note: Please be aware that this is a non-secure communication.