Individuals First Name Last Name Email Phone Ocuppation Date of Birth Questions Are you healthy - scale 1-10 12345678910 Last doctor visit Blood pressure A1C Cholesterol Triglycerides Height* Weight* Waist size in inches* How many medication do you take Have you had past procedures How much do you exercise How much alcohol per week do you consume* Do you smoke* YesNo Take illegal drugs* Have you been diagnosed with anything*
