|
Height
|
Weight (lbs)
|
|
Married
|
Single
|
|
# of children
|
|
|
|
|
|
Level of overall health (1-10)
|
Current prescription meds
|
|
Vitamins & herbal supplements
|
How often you exercise?
|
|
Here for what health issue?
|
Treatments tried before
|
|
What is diagnosis by MD?
|
How long affected by condition
|
