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Date
First Name
*
Last Name
*
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
May we leave a voicemail?
Yes
No
Email Address
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example@example.com
Date of Birth
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-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Weight
Marital Status?
Single
Married
Divorced
Widowed
Do you have children? Ages?
How Did You Hear About Us?
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Employer/Occupation
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My Main Health Problems Are:
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Which of the problems decrease your quality of life the most?
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In spite of the fact that you are not a doctor, you are in fact the person who knows more about your health than anyone else. In your opinion, what do you think the real problem is?
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Describe Your Present Symptoms:
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How often are you aware of your health problems?
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Please Select
I occasionally deal with them.
I definitely notice them, maybe daily.
I am constantly dealing with them.
How severe are your health problems?
Please Select
Slight: I can usually push through my day.
Moderate: It's challenging getting through my day.
Severe: I feel like it's debilitating.
Have others noticed or commented on your health? Y N What have they said?
What do you hope will transpire as a result of your consultation?
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Has your health caused you to lose time or miss out from the following?
Please Select
Family
Leisure
Work
If so, please elaborate:
What measures (diet or exercise programs, counseling, medical programs, Google, WebMD, etc) have you tried?
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Who is your biggest supporter when it comes to improving your health?
What are the top three things you've missed because of your condition?
Medications:
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Supplements:
Are you currently taking insulin?
HIGHEST your blood sugar gets WITHOUT medication:
HIGHEST your blood sugar gets WITH medication:
LOWEST your blood sugar gets WITHOUT medication:
LOWEST your blood sugar gets WITH medication:
Surgeries/Hospitalizations
Physical And/Or Emotional Trauma:
Past/Recent Illness:
If the answer was YES, what autoimmune condition(s)?
Have you had any imaging of your thyroid done recently?
Are you currently taking anti-rejection or immuno-suppressive medications?
What kind of conditions do people with your DNA develop as they age?
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Tobacco Products: Y or N
Alcohol: Y or N
Are you currently vegan or vegetarian?
How many days do you exercise each week?
List your 3 most important health goals in order of importance:
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On a scale of 1 to 10, rate your motivation to achieve these goals:
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On a scale of 1 to 10, how would you rate your stress:
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Select if you have or have ever had any of the following conditions:
Acne
Anxiety or Nervousness
Arthritis (Rheumatoid or Osteoporosis)
Bladder infections
Bloating, gas, indigestions
Bronchitis
Chronic fatigue
Cold sores
Constipation
Diarrhea
Depression
Difficulty losing weight
Difficulty gaining weight
Emotional problems (instability or sensitivity)
Gallbladder problems
Gout
Hair loss or Pair Hair growth
Headaches
Heartburn
Heart disease or problems
Herpes Simplex I or type II
High blood pressure
High cholesterol
Hot flashes
Loose stools
Memory Loss or confusion
Nails, poor growth
Panic attacks
Pregnant or nursing mothe
Ringing in ears
Severe mood swings
Skin conditions
Suicidal tendencies
Thyroid condition
Yeast infections
Give a list of all known allergies (to substances, foods, or environments):
*
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