Please fill this form out to the best of your ability. Please try to answer each question honestly and fully. Some questions only have one check box. This simply means if its not a problem there is no reason to answer the question.

Note: Once you start to fill out the form please know that if you exit out without first hitting the submit button, all your answers will be erased. So fill out this form when you can devote 10-15 minutes. All answers are held in strict confidentiality and will not be shared with anyone outside of Fleming Wellness Center’s staff.

PLEASE BRING ALL MEDICATION WITH YOU TO YOUR APPOINTMENT EVEN THOUGH YOU WILL FILL IT OUT ON THIS FORM. THANKS!

Name *
Name
Today's Date *
Today's Date
Address *
Address
Date of Birth *
Date of Birth
Sex *
Do you use any of the following
Do you consider yourself *
Have you had any significant weight changes in the last year?
Are you able to work without any problems?
Female Only: Are you or might you be pregnant?
Do you have a pacemaker?
Family History: Mother Side Of The Family (Click All That Apply)
Is your mother still alive?
Family History: Father Side Of The Family (Click All That Apply)
Is your father still alive?