Name		Age
Address		Gender	------- Male Female
Phone		Height
Email		Weight
Blood Type	------- don't know A B AB O
	Current health concerns
	Current Medications (prescription and OTC)
	Current Supplements (vitamins, protein powders, etc.)
	Please list the foods you typically eat for breakfast. Please list the foods you typically eat for lunch. Please list the foods you typically eat for dinner. Please list the foods you typically snack on between meals. How many glasses of water do you typically consume each day? ------- 1-3 glasses per day 4-6 glasses per day more than 6 glasses per day Please list all beverages (and amounts of each), other than water, that you typically consume each day. Do you smoke? ----- no yes Are you regularly exposed to cigarette smoke? ----- no yes What types of exercise do you currently participate in? How often do you exercise? ------ 1-3 x/week 4-6 x/week daily rarely Are there any activities which you enjoy that you would like to participate in more often? How many hours do you typically sleep each night? ------ 1-3 hours 4-6 hours 7-8 hours more than 8 hours Is there any additional information you would like to share?