Questionaire
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Email
Cell Phone Number
Format: (000) 000-0000.
How did you hear about us?
Occupation
Height
Weight
Are you Pregnant?
Yes
No
If so, What is your due date?
-
Month
-
Day
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?
Allergies
Bleeding
Breathing
Cancer
Constipation
Depression
Diabetes
Digestive
Dizzy Spells
Fluid Retention
Headaches
Heart
Heartburn/Bloating
High Blood Pressure
High Cholesterol
Joint Aches
Kidney
Leg Cramps
Low Blood Pressure
Menstrual Issues
Mood Swings
Nervous Tension
PMS/Menapuse
Skin Problems
Throat
Ulcers
Have you ever received an organ transplant or blood transfusion?
Yes
No
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:
Root Canal(s)
Implants
Amalgam (silver colored) fillings
Dental Surgery
Describe any dental issues/history:
Is there anything you haven't told me that you think I should know?
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