General Physicals
Please obtain the Patient Identifier number from us before applying. For privacy and security reason, do not fill in your name, email address and phone number here. Instead, only use your patient number in this form and other forms as well. This number is the identifier for each individual patient and the link for all Responses to Questions here to the same person. Therefore, do not use other people's number.
Patient Identifier *
Enter your Patient Identifier Number (PIN) only. Do not use other people's PIN.
Your answer
Height in inches
Enter total inches of your height, eg. 5' = 60", 6' = 72", etc.
Your answer
Weight in Pound
Enter numbers only
Your answer
Systolic Blood Pressure (mmHg)
The higher number appearing on reading. Enter number only.
Your answer
Diastolic Blood Pressure (mmHg)
The lower one appearing on reading . Enter number only.
Your answer
Fasting Blood Sugar (mg/dL)
Enter number only.
Your answer
Normal heart beats/min
This is the one when you are not sick. Enter number only.
Your answer
Marital Status
Smoking
No smoking at all
Heavily addicted
Alcohol drinking
No drinking at all
Heavily addicted
Drug addiction or Intoxication if any including marijuana
Your answer
List all allergen sources, including but not limited to food, drug, supplements, pollen, etc.
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List any or all prior medical conditions:
List any medication/purpose
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List any dietary supplement or essential oil/purpose
Your answer
Family medical history:
Your answer
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