Personal Information Username* First Name* Last Name* E-mail* Phone Number* Gender*MaleFemaleMale Female Date of Birth Address* Password* Repeat Password* Medical History Please list any drug allergies (if any) Have you ever had (Please check all that apply)AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema Other illnesses: Please list any Operations and Dates of Each Please list your Current Medications Healthy & Unhealthy Habits Exercise*Never1-2 days3-4 days5+ days Eating following a diet*I have a loose dietI have a strict dietI don't have a diet plan Alcohol Consumption*I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day Caffeine Consumption*I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day Do you smoke?*No0-1 pack/day1-2 packs/day2+ packs/day Include other comments regarding your Medical History Medical DocumentsUpload Medical Documents Creation Date* I agree to have my medical information stored online and made accessible to authorized medical professionals when necessary.*Send these credentials via email.
