Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Check all that apply for medical history
Other medical conditions not listed above:
Check all that apply for surgical history
Other surgery not listed above:
Check all that apply for family history
Please list all medications (prescription, vitamins, supplements, and herbals)
How many days of the week do you perform cardio aerobic activity (ex. brisk walk, run, bike, swim, dance)?
How many minutes do you perform the above cardio aerobic activity (on average) per day?
How many days of the week do you strength train (ex. lift weights, resistance bands)?
How many minutes do you do the above strength training activity (on average) per day?
What is your typical weekday bedtime?
What is your typical weekday wake up time?
What is your typical weekend bedtime?
What is your typical weekend wake up time?
How well do you think you sleep? (1=Not well at all, 5=Very well)
How long does it take for you to fall asleep?
Please list any sleep aids you use (medications, supplements/vitamins)
If you smoke tobacco products, how many packs per day?
If you smoke, how many years have you been smoking?
If you smoke, how many times have you attempted quitting?
Have you ever used cocaine or other illegal drugs?
If you drink alcohol, how many days of the week do you drink?
If you drink alcohol, how many drinks do you have per day (weeknight)?
If you drink alcohol, how many drinks do you have per day (weekend
How often do you have more than 4 drinks (female)/5 drinks (male) in a day?
“In most ways, life is close to ideal.” Rate this statement on a scale of 1-5 (1= not at all true, 2=rarely true 3= somewhat true, 4=mostly true, 5=very true).
1
2
3
4
5
Over the last two weeks, I have had little interest or pleasure in doing things
0
1
2
3
Over the last two weeks, I have felt down, depressed or hopeless
0
1
2
3
Over the last two weeks, I have been feeling nervous, anxious or on edge
0
1
2
3
Over the last two weeks, I feel like I have not been able to stop or control worrying
0
1
2
3
