Couples Info–Physical Health Please enable JavaScript in your browser to complete this form.Client Name *FirstLastHow would you rate your current physical health? *ExcellentGoodFairPoorWhat was the date of your last medical examination? *Doctor's Name *FirstLastDoctor's or Healthcare Facility Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you have any current serious or chronic medical conditions? If yes, list details. *Do you have any chronic pain, recurring body aches or soreness? Where is your body stress? *Have you had any serious acidents/head injuries/seizure activity? If yes, please list dates and details. *Please list all medications you are currently taking, along with dosages. *List all important past illnesses, injuries, surgeries and/or hospitalizations. *Do you smoke, and if so, how much? *Do you drink alcohol, and if so, how much? *Do you now have, or have you in the past had, a drug or alcohol problem? *NoYesDo you have any history of treatment for substance abuse problems? *NoYesClient Signature *Clear SignatureToday's Date *Submit