Health Condition & Medical History Form

Full Name* This field is required.The information you share with this form is only viewed, stored, and studied by me, in order to provide the best possible therapies/solutions, and it is protected by the Medical Confidentiality Law.

First Name

Last Name

Email Address* This field is required.

example@example.com

Contact Number* This field is required.

Current location* This field is required.

City

Country

1. What is your Gender? 2. Are you Pregnant, or planning to conceive soon? (for women)* This field is required.

Male

Female

I'm Pregnant

I'm planning to conceive soon

None of the above

What is your age?* This field is required.

What's your Weight* This field is required.

Extremely Underweight

Underweight

Slightly Underweight

Normal

Slightly Overweight

Overweight

Extremely overweight

What's your Occupation?* This field is required. Do you handle Chemicals, does your work stress your body?

Check the conditions that apply to you or any member of your immediate relatives:* This field is required.

Skin (Beauty - Repair - Cure)

Nutrition & Diet

Vitamins & Minerals

Hair & scull

Musculoskeletal

Asthma

Allergy

Respiratory

Hormonal

Reproductive System

Urinary System

Ears

Eyes

Stress - Depression

Neurological

Mental

Sleep

Time management

Psychological issue

Gastrointestinal

Cardiovascular

Lymphatic Issues & Lymphatic Detox

Other Organs

Diabetes

Detox

Cancer

Learn New Skills - Art Therapy

Something Else

Please describe the situation & symptoms you're currently experiencing, and/or the goals you want to achieve.* This field is required.Reproductive system

How long have you been experiencing this/those issue/issues?* This field is required.Describe in detail about any issue, separately

When was your last medical check up?* This field is required.

Please describe if you take any medications, and for what reason. (Natural therapies & Homeopathy included).* This field is required.Type "No" if you are not receiving any therapy and medication.

Do you have any medication and/or other allergies?* This field is required.

Yes

Not Sure

Please describe in detail if you have (or suspect) any medication/food/other allergies.* This field is required.Type "none" if there's no allergy

Please describe in detail if you have (or suspect) any food intolerances* This field is required.Type "none" if there's no intolerance

Please describe any health problems you experienced in the past.* This field is required.Type "None" if you haven't.

How often do you become ill (e.g. cold, flu, viruses, etc.)* This field is required.

Very rarely / never

1–2 times a year

3–5 times a year

More than 5 times a year

Do you smoke?* This field is required.Type "none" if there's no allergy

Daily

Occasionally

In the past

Never

Please check the options that describe your diet.* This field is required.

I consume Vegetables often / daily

I rarely / never consume vegetables

I consume fruits often / daily

I rarely / never consume fruits

I consume Meat often / daily

I rarely / never consume meat

I consume fish & seafood daily / often

I rarely / never consume fish & seafood

I consume processed foods often / daily

I rarely / never consume processed foods

I consume milk and dairy products often / daily

I rarely / never consume milk and dairy products

I consume carbs (pasta, bread, pizza, potatoes, sugars etc) often / daily

I'm on a low-carb diet

I consume nuts, seeds and legumes often / daily

I rarely / never consume nuts, seeds and legumes

I consume junk food often / daily

I rarely / never consume junk food

I'm a Vegan

I'm a Vegetarian

I'm a Pescatarian

I cook daily / often

I rarely / never cook

I cook healthy (no frying, no burnt fats, no chemical additives, etc)

I do not cook healthy

I consume sugars & sweets often / daily

I never / rarely consume sugars & sweets

Do you consume Salt? How much & what type of Salt do you use?* This field is required.E.g. A lot, little, normal (quantities), Himalayan Salt, Sea Salt, etc.

How many times do you eat & snack in a day?* This field is required.

Do you take any supplements? Please mark the supplements you take.* This field is required.

Vitamin D

Vitamin B12 - Cobalamin

Vitamin B3 - Niacin

Vitamin B2 - Riboflavin

Vitamin H - Biotin

Vitamin B1 - Thiamin

Vitamin B9 - Folate

Vitamin K

Vitamin E

Iodine

Calcium

Magnesium

Selenium

Chromium

Multivitamins

Fish oil

Probiotics

Curcumin

Spirulina

Herbs

Protein

Collagen

Other

I don't take supplements

Please describe in detail about every supplement you take, and the reasons why. Herbs included.* This field is required.Type "none" if you take no supplements

How often do you consume alcohol?* This field is required.Type "none" if there's no allergy

Daily

Weekly

Monthly

Occasionally

Never

Are you Vaccinated for covid & how many times?* This field is required.

Never

1 time

2 times

3 times

Do you get the yearly Flu Vaccination?* This field is required.

Never

In the past

Every year

I started this year

Please write any other useful information you think you should share with me.

Are you willing to adopt small daily changes to your routine, in order to achieve your goals and healing? Let me know how you feel about it.* This field is required.Please note that, as a therapist, I'm against drastic changes that would shock your organism and psychological status, which is overwhelming, and usually leads to withdraw, or relapse, or generates stress.

Upload any useful fileExample: Clear photos of skin conditions and/or other problems, Medical tests/results, etc

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Please solve the equation* This field is required.

Health Condition & Medical History Form