Do You, Or Have You Ever Had Difficulty With Any Of The Following?
Please answer all questions to the best of your ability, for multiple choice answers or question asking for more information please ad in answers in the notes box. (Do not forget)
GENERAL INFORMATION
Name
First Name
Last Name
Gender
Age:
Weight
Email Address:
Phone Number:
VITAL SIGNS
If You Are Unsure Of Any Of These Just Write I'm Unsure.
Blood Pressure (right & left)
Eye Color
Urine PH
Saliva PH
Resting Pulse
Basal Temperature
Are You Taking Any Medication Currently?
Are You Taking Any Herbal Supplements?
What Does You Current Diet Consist Of? Breakfast Lunch & Dinner?
What Do You Hope To Gain From This Program?
If You Have Any History Of Surgery Please explain here be detailed. If This Doesn't Apply Write. (Doesn't Apply)
If You Have Any Genetic /Family History Of Illness or Disorders Please Name Here Be Detailed. If It Doesn't Apply Write.... (It Doesn't Apply )
PANCREAS
*
Rows
Yes Currently Have
No
Not Sure
Slow Digestion
Does Food Passes Quickly Through You?
Do You Have Diarrhea Or Have You Had Diarrhea If So When Put In Notes?
Acid Reflux/ Heartburn /Indigestion
Undigested Food In Stool
Thin/ Difficulty gaining Weight
Moles (Also Adrenals)
Notes/ Add Additional Information
Thyroid/ Endocrine System
*
Rows
Yes Currently Have
No
Not Sure
Cold Hands or Feet
Frequently Cold/ Difficulty Warming
Easy To Gain Weight and Hard To Lose It
Irregular Heart Beat/ Arrhythmia's(Also Adrenals/ Cardiovascular) If experiencing any of these please list which one in notes below.
Headaches/ Migraines
Easily Irritable
Over-weight
Low Energy / Always Tired
Goiter / Hashimoto's / Grave's / Reidel's Disease
Family Member With Goiter / Hashimoto's / Graves /Reidel's Disease. If experiencing any of these please list which one in notes below.
How Much Do You Sweat?
Notes/ Add Additional Information
Parathyroid/ Endocrine System
Rows
Yes Currently Have
No
Not Sure
Are Your Fingers Ridged ?
Are Your Finger Nails Brittle?
Are Your Finger Nails Weak?
Muscle Cramps/ Legs Tired Easily?
Do You Have Strong Bladder?
Do You Have A Weak Bladder?
Do You Have A Bladder That Releases A Few Leaks
Varicose Veins/ Spider Veins If experiencing any of these please list which one in notes below.
Hemorrhoids/ Prolapses
Hernia
Aneurysm
Low Bone Density/ Low Calcium If experiencing any of these please list which one in notes below.
Osteoporosis / Scoliosis / Kyphosis / Lordosis
If experiencing any of these please list which one in notes below.
Mental Health Challenges (Depression, PTSD, OCD Etc...If experiencing any of these please list which one in notes below.
Spinal Deterioration / Hernia Discs / Bone Spurs If experiencing any of these please list which one in notes below.
Bruise Easy?
Notes/ Add Additional Information
Adrenals (Glandular)
Rows
Yes Currently Have
No
Not Sure
Overweight
MS / ALS / Parkinson's / Palsy
Anxiety
Tremors / Nervous Legs
High Blood Pressure (Also Cardiovascular)
Low Blood Pressure
Hypoglycemia (Low Blood Sugar)
Diabetes: TYPE I / TYPE 2 If experiencing any of these please list which one in notes below.
Tinnitus (Ringing in Ears)
Difficulty Taking Deep Breath / S.O.B (Short of Breath) If experiencing any of these please list which one in notes below.
Cardiac Arrythmia : (Also Cardiovascular) If experiencing any of these please list which one in notes below.
Sleep Challenges...Difficulty Getting to Sleep? (Also Pineal)
Sleep Challenges..Difficulty Staying Asleep?
CFS (Chronic Fatigue Syndrome)?
Addison's Disease / Congenital Adrenal Hyperplasia If experiencing any of these please list which one in notes below.
High Cholestero?l
Low Steroids / Low Cortisol?
Do You Have Arthritis?
Do You Have Osteoarthritis?
Do You Have Brusitis?
Do You Have ADD?
Do You Have ADHD?
Are You Autistic?
Notes/ Add Additional Information
Females Only
Rows
Yes Currently Have
No
Not Sure
Are You Currently Pregnant?
Are You Currently Breastfeeding?
Do you have irregular Menses? (Also Pituitary)
Do you have excessive Bleeding During Menstruation?
Do You have Ovarian Cysts or Fibroids?If experiencing any of these please list which one in notes below.
Endometriosis / A-Typical Cells?If experiencing any of these please list which one in notes below.
Fibrocystic Breasts?
Sore or Painful Breasts, Especially During Menstruation?
Low / Excessive Sex Drive?
Have You Had a Complete Hysterectomy / Partial Hysterectomy?
If Yes, Were Any Other Organs / Lymph Nodes Removed? Please List Which in Notes?
Difficulty Conceiving?
Sleep Challenges...Difficulty Staying Asleep?
Birth Control Pills? For How Long?
Notes
Males Only
Rows
Yes Currently Have
No
Not Sure
Do You Have Prostatitis? How Often do You Urinate?
Have You Been Diagnosed with Prostate 'Cancer'?
What are Your PSA's?
Testicular Hypertrophy (Enlarged Testicles)?
Low / Excessive Sex Drive?
Erection Problems?
Fibrocystic Breasts?
Premature Ejaculation?
Notes/ Add Additional Information
Gastro- Intestinal-Tract
Rows
Yes Currently Have
No
Not Sure
1 Bowel Movements per Day?
2 Bowel Movements per Day?
3 Bowel Movements per Day?
Do You Have Crohn's?
Do You Have Colitis?
Do You Have Gastritis ?
Do You Have Enteritis ?
Do You Have Diverticulitis?
Gastroparesis (Paralysis of the Stomach)?
Do you or have you ever had a Hiatus Hernia?
Is Your Tongue Coated, Especially Upon Waking (White)?
Is Your Tongue Coated, Especially Upon Waking (Green)?
Is Your Tongue Coated, Especially Upon Waking (Yellow)?
Is Your Tongue Coated, Especially Upon Waking (Brown)?
Do You Have Diarrhea / Constipation?
Do You Have Stomach / Intestinal Ulcers?
Do You Have Gastro-Intestinal 'Cancer?
Notes/ Add Additional Information
Live/Gallbladder/Blood
Rows
Yes Currently Have
No
Not Sure
Difficulty Digesting Fats?
Fats or Dairy Cause Stomach Bloat / Pain?
Light Colored or White Stools?
Pain Mid-Back (Especially After Eating)?
Liver' or Brown Spots (Not Freckles)?
Skin Pigmentation Irregularities or Changes?
Jaundice of Eyes / Skin?
Do You Have Anemia?
Hepatitis A, B, or C?
Do You Consume Alcohol?
Notes/ Add Additional Information
Cardiovascular
Rows
Yes Currently Have
No
Not Sure
Angina / Chest Pain?If experiencing any of these please list which one in notes below.
Myocardial Infarction (Heart Attack)?
Pacemaker / Stents / Other Open-Heart Surgery?If experiencing any of these please list which one in notes below.
Do You Feel Pressure on Your Chest?
Do You Feel 'Prickly' Pains? If experiencing any of these please list where in notes below.
Notes/ Add Additional Information
Skin
Rows
Yes Currently Have
No
Not Sure
Blemishes / Rashes / AcneIf experiencing any of these please list which one in notes below.
Dermatitis / Eczema / PsoriasisIf experiencing any of these please list which one in notes below.
Dry, Itchy SkinIf experiencing any of these please list which one in notes below.
Excessively Oily Skin
Dandruff
Any Other Skin Problems Please List In Notes Below.
Notes/ Add Additional Information
Lymphatic System
Rows
Yes Currently Have
No
Not Sure
Hair Loss / Balding / Fully Bald (not by choice)
Have You Ever Had Any Lymph Nodes Removed? If so please list where in the notes below.
Swollen Lymph Nodes / Lymphedema (Specify In Notes)
Do You Have Edema (Fluid Retention)? Please Provide Location In Notes?
Fibromyalgia / Scleroderma
Cold & Flu-like Symptoms
Sore Throat / Sinus Problems
Poor Memory / Brain Fog
Blurred Vision
Mucus in Eyes Upon Waking
Have You Been Diagnosed With 'Cancer'? If experiencing any of these please list which one in notes below.
Other Type of Non-Malignant Mass / Tumor
Location of Non-Malignant Mass / Tumor? Please Provide Where In Notes?
AIDS / HIV +
Low Platelet Count (Also Cardiovascular)
Appendicitis / Appendectomy
Date of Appendicitis / Appendectomy:
Date of Tonsillectomy (Tonsils Removed):
Do You Have Boils?
Do You Have Abscesses?
Do You Have Cysts
Gout
Toxemia / Cellulitis
Sleep Apnea
Do You Snore?
Notes/ Add Additional Information
Kidneys / Bladder
Rows
Yes Currently Have
No
Not Sure
Hair Loss / Balding / Fully Bald (not by choice)?
Burning While Urinating?
Weak Bladder / Urinary Incontinence?
Restricted Urine Flow?
Do have or have you ever had Kidney Stones?
Do you have nephritis?
Cramping or Pain Mid-to Lower Back on Either Side
Lower Back Weakness / Lack of Strength
Sciatica?
Bags Under Eyes?
Notes/ Add Additional Information
Respiratory System
Rows
Yes Currently Have
No
Not Sure
Do You Have Bronchitis?
Do You Have Asthma?
Do You Have COPD?
Do You Have Emphysema?
Pain / Difficulty Breathing
Frequent Cough?
Collapsed Lung: Right or Left?
Pain / Difficulty Taking Deep Breaths (Also Adrenals)?
Color of Mucus Expectorated: Clear
Color of Mucus Expectorated: Yellow
Color of Mucus Expectorated: Green
Color of Mucus Expectorated: Brown
Color of Mucus Expectorated: Black
Do You Use a: Nebulizer / Inhaler
What is Your Oxygen Saturation (or SP02)?
Have You Been Diagnosed with Lung 'Cancer'?
Are You a Smoker?
Do You Smoke A Pack A Day?
Do You Smoke A Few Cigs A Day?
Notes/ Add Additional Information
Environmental Or Other Toxic Exposure
Rows
Yes Currently Have
No
Not Sure
Exposure to: Nuclear Wastes / By-Products of Nuclear Wastes / Heavy Metals / Toxic Chemicals
Exposure to Toxic Substances Such as Asbestos or Coal Mines (Also Respiratory System)
Have You Gone Through Chemotherapy or Radiation?
How Many Treatments of Chemo or Radiation?
Have You Received the "Standard" Vaccinations?
Have You Received Vaccinations for Traveling To Foreign Countries?
Have You Received a Flu Shot?
Have You Ever Used 'Recreational' Drugs? (This information is confidential and used to help you attain optimal health only!)
Please List Any 'Recreational' Drugs You Have Used In Notes Below
Notes/ Add Additional Information
Submit
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