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General Information

First Name

Last Name

Gender

Male

Female

Profession

Education

Email

Telephone Number

Mobile Number

Address

Apt, suite, etc.

CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabwe

City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin Islands

Zip code

Date of birth

Weight(kg/Lbs)

Height(in Feet & Inches)

Medical History

About Parents (Have they been suffering with)

Cardiac Problem

Father

Yes

No

Mother

Yes

No

Low or High Blood Pressure

Father

yes

No

Mother

Yes

No

Asthma

Father

Yes

No

Mother

Yes

No

Diabetes

Father

Yes

No

Mother

Yes

No

Cancer

Father

Yes

No

Mother

Yes

No

Hypo or Hyper Thyroidism

Father

Yes

No

Mother

Yes

No

Hypo or Hyper Thyroidism

Father

Yes

No

Mother

Yes

No

Adrenal Fatigue

Father

Yes

No

Mother

Yes

NO

Kidney failure

Father

Yes

No

Mother

Yes

No

Migraines

Father

Yes

No

Mother

Yes

No

Digestive Disorders

Father

Yes

No

Mother

Yes

No

Any other major health problem

Father

Yes

No

Mother

Yes

No

Please Specify Below

About You

Previous Illness (in last 10 years but doesn’t exist now)

If Yes Please specify below

Any major surgery

Nature of surgery

Date of surgery

Any complication after Surgery

Any accident

Nature of Accident

Date of Accident

Any complication after Accident

Current illness

Migraines

Yes

No

Allergy

Yes

No

Allergic to- Please Specify

Weight Loss

Yes

No

Weight Gain

Yes

No

Thyroidism (Hypo)

yes

No

Thyroidism (Hyper)

Yes

No

Throat Problem

Yes

No

Nose Problem

Yes

No

Eye Problem

Yes

No

Ear Problem

Yes

No

Sleeping Disorders (Insomnia)

Yes

No

Sciatica

Yes

No

Stress

Yes

No

Stiffness

Yes

No

Skin Problem

Yes

No

Respiratory Problem

Yes

No

Psychiatric Problem

Yes

No

Osteoporosis

Yes

No

Neurological Problem

Yes

No

Musculoskeletal

Yes

No

Menopause Symptoms

Yes

No

Lymphatic

Yes

No

Low Pulse Rate

Yes

No

Low Blood Pressure

Yes

No

High Blood Pressure

Male

Female

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