Name

Date of Birth

Sex

• Male

• Female

Phone number

Email

Address

Do you smoke?

• Never

• Rarely

• Occasionally

• Frequently

• Always

Do you consume alcohol?

• Never

• Rarely

• Occasionally

• Frequently

• Always

Do you use recreational drugs?

• Never

• Rarely

• Occasionally

• Frequently

• Always

How often do you exercise?

• Never

• Occasionally

• 1-2 times per week

• 3-5 times per week

• Daily

Do you follow a special diet?

If yes, please specify:

Does anyone in your immediate family have a history of the following conditions?

Select all that apply:

• Heart Disease

• Diabetes

• High Blood Pressure

• Cancer

• HIV

• Stroke

• Mental Illness

• None

Have you been diagnosed with any chronic conditions?

If yes, list conditions:

Are you currently taking medications?

Current Medications

Do you have any allergies?

Please specify, if any:

Current Symptoms

Please select the symptoms you are currently experiencing, if any:

• Fever

• Cough

• Fatigue

• Headache

• Shortness of Breath

• Chest Pain

• Dizziness

• Nausea

• Joint Pain

• Rash

• None

How long have you been experiencing these symptoms?

• Less than 1 week

• 1-2 weeks

• 2-4 weeks

• Over a month

On a scale of 1 to 5, how would you rate your pain or discomfort?

Have your symptoms worsened in the last 48 hours?

Do you have any other concerns or symptoms that haven't been addressed?

If yes, please specify: