Full Names:

Date of Birth:

Blood group:

Religion/belief system:

Height:

Weight:

Profession:

Marital status:

Children:

Diagnosis:

Main complaints:

Medical reports:

Blood results:

Photos of the eyes, ears, face, tongue, teeth, hands, feet, full body front, side and back:

Flossing frequency:

Number of amalgams:

Number of root canals:

Poisonings:

Allergies:

Operations:

Blood transfusions:

Head injuries:

Body injuries:

Vision:

Hearing:

Smoking:

Drinking:

Coffee:

Ordinary tea:

Cold drinks:

Chewing gums:

Diet: carbohydrate, protein or mixed?

Number of meals per day:

Microwave oven use:

Margarine/canola oil consumption:

Mothballs/naphthalene presence at home:

Hormonal contraception (women only):

Glasses of water per day:

BP:

Resting heart rate per minute:

Hours and type of exercise per day:

Hours of sleep:

Hobby:

Fasting glucose:

Fasting cholesterol:

Full blood count:

Uric acid:

Lipoprotein (a):

Homocysteine :

Thyroid function and antibodies:

Kidney function:

Liver function:

D-dimer:

Medication:

Supplements:

Email:

Phone No:

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