Questionaire

Questionaire
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
Cell Phone Number
Format: (000) 000-0000.
How did you hear about us?
Occupation
Height
Weight
Are you Pregnant?
If so, What is your due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
What are the ages of your children?
Describe your daily meals:
Breakfast
Lunch
Dinner
Snacks
Describe your daily fluid intake
Water
Coffee/Tea
Juice
Alcohol
Soda
Other
What type of water do you drink?
(tap, bottle, filtered, etc.)
How much sleep do you get on average?
Is it sound?
Do you have urinary urgency?
Number of bowel movements daily:
Describe your energy level:
What causes you stress?
What do you do when you are stressed?
Are you currently under the care of an M.D.?
List any medications you are currently taking, including birth control:
List any supplements you are currently taking:
Have you ever had or been diagnosed with any of the following?
Have you ever received an organ transplant or blood transfusion?
If Yes, please explain
List your 4 main health complaints in order of importance:
List any known allergies:
Present diagnosis, illness, or disease:
Brief history of illnesses & treatments:
Operations, accidents, and injuries:
Family history of illnesses or diseases:
List or describe any vaccinations (Childhood, Specialty ie travel or local contagion, Covid, etc.) you have had, approximate age & reason:
Have you had any of the following dental work:
Describe any dental issues/history:
Is there anything you haven't told me that you think I should know?
Should be Empty:

Questionaire

Describe your daily meals:

Describe your daily fluid intake