Lifestyle Medicine Options
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Chip Program
CPR, AED and First Aid
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Health History Questionnaire
Agreement to Receive Electronic Communication
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General Patient Information Form
New Patient Assessment Form
24 Hour Food Options Form
Request to Participate (CHIP)
Request to Participate (LIFT)
What is Lifestyle Medicine
About
Services
Chip Program
CPR, AED and First Aid
Genetic Testing - Nutrigenomics & Pharmacogenomics
The Lift Project
1-on-1 Program
Diabetes Prevention Program
Programs + Products
Network
Providers
Employers
Partners
Resources
Helpful Links
FAQ
Patient Forms
Health History Questionnaire
Agreement to Receive Electronic Communication
Payment Policies
General Patient Information Form
New Patient Assessment Form
24 Hour Food Options Form
Request to Participate (CHIP)
Request to Participate (LIFT)
Blog
Lifestyle Medicine Options
Contact
Lifestyle Medicine Options
General Patient Information
Open the General Patient Information Form
General Patient Form
Patient Name
*
First Name
Last Name
Patient Height (cm's)
*
Patient Weight (kg's)
*
Email
*
Reason For Seeing the Doctor
Please list any Drug Allergies
*
Have you ever Had
*
(please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy
Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Please list any operations and dates of Each
*
Please list your current Medications
*
Exercise
*
Never
1-2 days
3-4 days
5+ days
Diet
*
I have a loose diet
I have a strict diet
I don't have a diet plan
Alcohol
*
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine
*
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you Smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Include other comments regarding your Medical History
*
Thank you!