Health and Lifestyle Survey

For New Optimal Health Institute Clients

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Please complete the following Health and Wellness survey by filling in the forms below. This information is required for evaluation of new clients, and your answers will be kept secure and confidential. Please complete all required fields. Thank you for your interest in living well with Optimal Health!

Questions marked with a * are required.

 
*1. First, please tell us how you learned about the Optimal Health Institute?
Our Website
Natural Awakenings Magazine Ad
Current Optimal Health client (please specify name below)
Other: 
 
*2. (First Name, Last Name)
 
*3. Enter the date you are completing this survey.
 
*4. Street Address, City, State, Zip
 
*5. Enter your primary contact number (ex. 423-778-9470)
 
*6. Confidential e-mail (for sending confidential medical information)
 
7. Confidential Fax Number (to send you confidential medical information)
 
*8. Please select your gender.
 
*9. Enter your weight below.
 
*10. Select your body frame size:
 
11. Select your blood type from the dropdown menu.
 
12. Please enter the name and phone number of your Personal Physician.
 
*13. Please enter your date of birth.
 
*14. Please enter your current marital status.
 
*15. How many children do you have?
 
16. Please list other persons living in your household.
 
*17. What is your current occupation?
 
*18. How would you rate your current health?
 
*19. What are your health-related goals?
 
*20. What are your expectations as a client of Optimal Health Institute?
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