Statement of Health Form
Personal Information:
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health History:
General Health:
Excellent
Very Good
Good
Fair
Poor
Medical Conditions:
Medications:
Allergies:
Lifestyle:
Diet:
Vegetarian
Vegan
Omnivore
Other
Physical Activity:
Sedentary
Lightly Active
Moderately Active
Very Active
Smoking:
Non-smoker
Former smoker
Current smoker
Alcohol Consumption:
Non-drinker
Moderate drinker
Heavy drinker
Family Medical History:
Family History:
Routine Health Checkups:
Last Medical Checkup:
Any Other Relevant Information:
Authorization:
*
I hereby authorize the release of this information.
Signature
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: