Synergy Formulas

Email

example@example.com

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

What is your Gender?

Date of Birth

MonthDayYear

Check the conditions that apply to you :

Other condition/s not listed above

Check the symptom/s that you have experienced in the past 12 months.

Symptom/s not listed above.

Do you have implants ie. dental, hip/knee replacement, breast?

Other

If you have implant/s ex:. dental, knee, hip, breast etc. Please list below and how long you've had them:

Are you currently taking any medication?

If so, please list:

Typical daily diet, please be specific.

List any emotional traumas/episodes with approximate dates as far back as you like. Example: Bereavements, divorce ( yours or your parents), accidents, loss of a job, home etc.

Do you have any other medical conditions, injury or anything else you would like to mention?

The areas, problems and goals you wish to address.

Overall how healthy do you feel ?

I understand that Joni Micals, ND does not give a medical diagnosis or treatment and it is my responsibilty to seek a GP for any medical problems I may be experiencing.

Name

Today's Date

MonthDayYear

Questionnaire