THIS IS OPTIMUM HEALTH
Please PRINT the form below, fill it in and send it to us along with your payment for processing.

PRESCRIPTION HEALTH
822 North 4th Street
Longview, TX. 75601
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What is your current AGE?

What is your HEIGHT?

What is your WEIGHT

What is your OCCUPATION?

What is your ACTIVITY LEVEL?(choose one below)
VERY ACTIVE (exercise:cardio and resistance at least 5 times per week)
ACTIVE (exercise 3 or more times per week)
INACTIVE (exercise less than 3 times per week)

MEDICAL DIAGNOSIS:
LIST ANY CONDITIONS YOU CURRENTLY HAVE AND THE TYPE IF APPLICABLE
(i.e.Arthritis, Type:Osteoarthritis, Rheumatoid, Other
Cancer, Cardiovascular Disease, Chronic Fatigue Syndrome,
Diabetes, Fibromyalgia, Gastrointestinal, Hypertension, Kidney Disease,
Liver Disease, Obesity, Post-menopausal, Pregnant, Ulcer, OTHER (please list)

Do you have Hypercholesterolemia (High Cholesterol)?
If YES, please give your family history of high cholesterol.

When were you first diagnosed with the conditions you have? (i.e., MONTH, DAY & YEAR)

Please describe any physical limitations you may have:
(i.e., Not at all, A little, Moderate, Very)

Are you allergic to any medications?
If Yes please list them by name:

List any supplements you are currently taking:

List all over the counter and prescribed medications you are taking:

What do you hope to accomplish by changing your diet?

What is your name?

What is your mailing address?(include street, city & zip)

What is your phone number? (area code first)

Have you attached your check?(yes/no)

WHAT IS YOUR EMAIL Address? (enter carefully)