Student Why Try Registration Form - Acts of Love Church of Christ

WHY TRY

Student Registration Form

Parent/Guardian First Name *

Parent/Guardian Middle Name

Parent/Guardian Last Name *

Parent Email Address *

Occupation

Home Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Mobile/Home Phone *

Parent Work Phone

Student First Name *

Student Middle Name

Student Last Name *

Gender *MaleFemale

Date of Birth *

Age *

Name of School/Organization:

School/Organization Phone

School/Organization Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

How did you hear about us?

Medical History Intake Form

Name of General Practitioner or Doctor

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Please indicate if you have had any of the following concerns in the past year, or of significance in the past couple of months.

Please list anything else or elaborate on the above if you would like.

Health Assessment and Medical Information

Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..YesNo

Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products?YesNo

Any known allergies?

Dietary and Lifestyle Habits

How often do you exercise?Times per week

What kind of exercise?

Do you have any known (or suspected) food allergies or intolerances?YesNo

Please list:

Do you have any dietary restrictions? (e.g., religious, vegan/vegetarian)YesNo

Please specify

Please indicate how many cups of the following you drink per day, based on a standard mug size.

Water

Coffee

Tea

Herbal Tea

Juice

Cola

Please list which kinds, and how often.

Sleep, Energy and Stress Levels

On average, how many hours of sleep do you get?

Do you have difficulty falling asleep?YesNoSometimes

What are some stressors in your life?

Please quickly rate your level of satisfaction with the following areas of your life. (1 = not satisfied, 5 = very satisfied)

Is there anything else you would like to add that you feel is important and has not been covered?

Thanks for taking the time to complete this intake form.

Signature *