Client Data Form

Height & Weight
What is your current height?*
(ex. 5'09")
What is your current weight?*
Please round up to the nearest pound. (ex. 126.5 = 127)
Have you experienced a weight change of 10 pounds or more in the last 12 months?*
- Yes
- No
Pounds lost?
Pounds gained?
Reason for change?

Tobacco Use
Have you EVER used tobacco in any form, or smoking cessation products (such as e-cigarettes, nicorette, chantix, etc.)?*
- Yes
- No
Product(s) used?
Frequency of use?
Date of Last Use
MM slash DD slash YYYY

Other than indicated previously, in the past 5 years, have you had any illness, injury, surgery, physical exam, consultation or medical test (ex. laboratory tests, EKG, etc.), or been a patient in a hospital or other medical facility?*
- Yes
- No
If yes, please provide a description that includes the diagnosis, date of diagnosis, treatment, and doctor's name and facility where you were diagnosed.

Are you currently receiving any treatment or taking any prescription or nonprescription medications or supplements?*
- Yes
- No
If yes, please provide a description that includes the diagnosis, date of diagnosis, treatment, and doctor's name and facility where you were diagnosed, and the medication prescribed.
Do you have any surgery, medical test, treatments or visits with a health professional scheduled in the next six months?*
- Yes
- No
If yes, please provide a description of what is planned and when. Also, include the diagnosis, date of diagnosis, treatment and doctor's name and facility where you were diagnosed.
Have you ever been diagnosed with, are treated by a member of the medical profession, for Acquire Immune Deficiency Syndrome (AIDS),AIDS Human Immunodeficiency Virus (HIV), or the antibodies to the AIDS (HIV) virus?*
- Yes
- No
If yes, provide a description that includes the diagnosis, date of diagnosis, treatment and doctor's name and facility where you were diagnosed.

Have you ever used cocaine, heroin, or other illicit drugs or controlled substances EXCEPT as prescribed by a health professional?*
- Yes
- No
If yes, provide the type of substance used, the initial date used, the frequency of use, and the date of last use.
Have you ever sought, been advised to seek, or received counseling or treatment for the use of alcohol or drugs by a health professional or support group?*
- Yes
- No
If yes, please provide a description to include the diagnosis, date of diagnosis, treatment and doctor's name and/or facility where you were diagnosed. Also, provide the date of last use and if you are active with a support group currently.

Family History
Does your father have any history of cancer, cardiac disease or diabetes prior to age 60?*
- Yes
- No
If yes, please detail the age he was diagnosed & type of cancer, cardiac disease or diabetes.
If applicable, age of father's death?
If applicable, cause of father's death:
Does your mother have any history of cancer, cardiac disease or diabetes prior to age 60?*
- Yes
- No
If yes, please detail the age she was diagnosed & type of cancer, cardiac disease or diabetes.
If applicable, age of mother's death?
If applicable, cause of mother's death:
Do(es) your sibling(s) have any history of cancer, cardiac disease or diabetes prior to age 60?*
- Yes
- No
If yes, please detail the age of diagnosis, and types of cancer, cardiac disease or diabetes.
If applicable, list the ages and causes of sibling(s) death.

Personal History
Within the last five years, have you filed for bankruptcy, or had any judgments or liens filed against you?*
- Yes
- No
If yes, discharge date:
MM slash DD slash YYYY
Have you ever been convicted of a misdemeanor or felony?*
- Yes
- No
If yes, please provide details of charges and conviction.
Are you currently receiving workers' compensation, social security or disability income?*
- Yes
- No
If yes, please provide the start date and reason.

Insurance History
Have you ever had life, health, or long term care declined, rated or issued other than you had applied for?*
- Yes
- No
If yes, please provide the date of, and reason for, the decline:
Phone
This field is for validation purposes and should be left unchanged.

Personal Information