Here is an example of a form that captures data.

First Name:
Middle Initial:
last name:
last name:
Sex: male female N/A
Birthday:

Height(inches):
Weight(pounds):

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Phone Number:

Marital Status: select a status single married divorced legally separated widowed
Address:
city:

state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
zip:

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Taking Medications: yes no

if yes,list medications here:

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