General Health QuestionnaireAll information provided will be kept confidential. Name * First Name Last Name What is your occupation? * Cigarette Smoking * Please check all that are applicable I smoke cigarettes I am exposed to second hand smoke I do not smoke cigarettes Pain Please check all that are applicable Headaches Face pain (TMJ, etc.) Neck pain Shoulder pain Back pain (upper, mid, lower) Leg pain Foot/Ankle pain Diet Please check all that are applicable No restrictions Gluten-free Paleo Keto Vegetarian Vegan Other Other Diet If you checked "Other Diet", please describe your diet. Estimate your weight in lbs. * Estimate your height in feet and inches * Exercise * Please check all that are applicable I exercise regularly. I do not exercise. Supplements Please check all that are applicable Vitamin C Vitamin E Vitamin D Multivitamin Other Other Supplements If you checked "Other Supplements" above, please list other nutritional supplements you are taking not included above: Skincare routine Please check all that are applicable I don't do anything in particular I have a daily regimen I have a weekly/monthly I use sunscreen daily when I am outside I use sunscreen when I spend time in front of the computer Allergies or Sensitivities I have allergies I have specific sensitivities Please specify your allergies or sensitivities. Face procedures or surgery I previously underwent cosmetic procedures (botox, fillers, etc.) or surgery. I have previously taken a facial exercise program or have used facial toning products. Please indicate the area of the face that received botox, fillers, or underwent cosmetic surgery and the most recent date. Overall health Please describe anything else you think I should know about your overall health? Thank you!
