INFORMATION *Username: *Password: *Confirm Password: *First Name: Middle Name: *Last Name: *Date Of Birth:   *Sex: Male Female Height: ft. in. Weight: lbs. *Primary Phone Number: Secondary Phone Number: Fax Number: *Email:   MEDICAL HISTORY *Primary Physician's Name: *Physician's Telephone:      Current Medications Taken: Medicine Strength Frequency Duration      Allergies: Allergie1: Allergie2: Allergie3: Allergie4: Allergie5:    Patient Medical Conditions: Smoker Yes No Emotional Mood Disorders Yes No Glaucoma or other eye disorders Yes No Musculoskeletal and arthritic disorders Yes No Respiratory disorders (breathing problems) Yes No Cancer Yes No Heart disease: high blood pressure, heart disease, angina, heart failure, heart attack, arrhythmias or heart surgery Yes No Blood disorders Yes No High lipids and triglycerides Yes No Neurological disorders Yes No Stomach, liver, intestinal disorders Yes No Dermatological disorders Yes No Renal or kidney disease including prostate disease Yes No Diabetes, thyroid or other endocrine disorders Yes No Other Yes No If you have selected "Yes" to any of the above fields, please enter more details:

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