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Personal History   Dear Patient, This form is designed to help us find the cause of your current health problem as quickly as possible. The more detailed and accurate you are, the better care we can provide. Your overall health is just as important to us as your current major complaints. No symptom is insignificant. The more you tell us, the more we will be able to help you achieve your health goals. This survey should take you 5-10 minutes to complete.  (Pages 1-5 are REQUIRED)   Date: First Name: Last Name: Home Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other Zip: Home Phone: Business Phone: Email Address: Age: Birth date: Sex: MaleFemale Height: Weight: Type of work: Vegetarian: Yes No