Synergy Formulas

Questionnaire
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?

MaleFemale
Date of Birth*

MonthDayYear
Check the conditions that apply to you :

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Other condition/s not listed above
Check the symptom/s that you have experienced in the past 12 months.*

DiarrheaConstipationUnexplained change in weightFatigue/Malaise/Generalized weaknessHeadaches/MigrainesDizzinessSinus Pain/Pressure/DischargeExcessive snoringWheezing/Chronic CoughShortness of breathChest pain, pressure or tightnessSwelling of hands/feet/anklesNausea/VomitingAbdominal painHeartburnStiffness/Pain in joints/musclesJoint swellingBleeding/Easy bruisingExcessive urinationExcessive thirst/hungerHot flashesPainful/Bloody urinationDifficulty urinating/Night-time urinationUrinary incontinence (leakage)Sexual Difficulties/Painful intercourseRash-Hives-PsoriasisAnxiety/Panic AttacksConcentration DifficultyFeelings of GuiltMood SwingsEasily startledFearAngerInsomnia/Problems with SleepLoss of energyMemory LossConfusionAuto ImmunityFood allergiesInhalant allergiesFrequent IllnessNone of the above
Symptom/s not listed above.
Do you have implants ie. dental, hip/knee replacement, breast?*

YesNoOther
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?

YesNo
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
Should be Empty:

Questionnaire