CONFIDENTIAL HEALTH QUESTIONNAIRE

CONFIDENTIAL HEALTH QUESTIONNAIRE
Disclaimer: The information provided in this history intake form is for research and educational purposes only. Completion of this form does not constitute a binding agreement for healthcare services, medical diagnosis, or treatment. The Cellular Health Foundation does not provide direct medical care, prescribe treatments, or make guarantees regarding health outcomes.

This form is intended solely to assist in gathering information for educational and research purposes. It should not be considered a substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider. By submitting this form, you acknowledge that participation is voluntary and that any health-related decisions should be made in consultation with your personal healthcare provider.

If you have a medical emergency, please contact a licensed medical professional or call emergency services immediately.
DoctorPatient
BLOOD TEST INFO

This section is for physicians.
Today’s Date

MonthDayYear
Date
Main Diagnosis:
Patient Name

First NameLast Name
Birthdate

MonthDayYear
Date
Sample ID# or Requisition#:
Tracking or Airbill #:
Doctor’s Name:
Date Blood Drawn:

MonthDayYear
Date
CONTACT INFO
PATIENT’S NAME:*
Date of Birth:

MonthDayYear
Date
Spouse’s Name OR Parent’s Names: (if patient is a child)
Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:*
example@example.com
Emergency Contact:
Please enter a valid phone number.Format: (000) 000-0000.
Phone: *
Please enter a valid phone number.Format: (000) 000-0000.

MEDICAL HISTORY
List the main problems that you are having - current medical problems / date started:
List Known Allergies to medication and type of reactions to:
List Current Medications / Drugs / Hormones and Amount Taking (not nutrients):
Height:
Weight:
Blood Type:
BMI:
Blood Pressure:
Pulse:
Eye Color:
Hair Color:

Supplements

Please list all vitamins and supplements that you are taking.

Rows	Name	Manufacturer	Form	Dosage and Frequency
1
2
3
4
5
6
7
8
9
10
11
12
13
15
16
17
18
19
2o
21
22
23
24
25
26
27

Dietary History Form

Please fill out the following with what your diet consists of. List dressing / oils / butter. Please beas specific (what kind of vegetable, cereal, protein, starch, etc.) And honest as possible!
BREAKFAST: Time Consumed
SNACK:
LUNCH: Time Consumed
SNACK:
DINNER: Time Consumed
SNACK:
History
Please list all Accidents and Injuries:
Please List all Surgeries/ Hospitalizations
Please list all Countries you have Traveled to or Lived in the Past:
Your Hobbies & RecreationalInterests:
Where was your place of birth?
States where you lived in the past:
Your Profession: (past, current)
Did you serve in the military?
Date of Service:

MonthDayYear
Date
Do you see a dentist regularly?
Name of Dentist:
How many silver fillings did you have?
How many silver fillings do you have now?
How many root canals do you have?
Any tooth implants/Dentures?
Have you had your fillings removed?
When?
Natural Dentist?
TapWellBottledFiltered
Which ones?
PesticidesMoldChemicalsSolvents
Which ones?
What are your goals to improve your health?
Should be Empty:

Rows	L	M	H
Sesame Oil
Safflower Oil
Flax Oil
Sunflower Oil
Walnut Oil
Olive Oil
Canola Oil
MCT Oil
Soy Oil
Cottonseed Oil
Peanut Oil
Corn Oil
Avocado Oil
Mustard
Lard
Crisco
Salad Dressing
Mayonnaise
Margarine
Butter
Coconut Oil

Rows	Daily	Weekly	Occasionally	Never	Past
Coffee/caffeine
Tobacco ( packs/day)
Cannabis Use / CBD
Alcohol
Recreational Drugs – (list/circle) Psychedelic Mushrooms, Ecstasy, Cocaine
Laxatives
Exercise
Prayer, Meditation

Rows	M	F	B	S	G	C	A	U
Allergies or Asthma
Alcoholism
Heart disease
Alzheimer's
Epilepsy, seizures
Psychiatric
Stroke
High blood pressure
Hypoglycemia
Diabetes
Neurologic disease

Rows	Past	Present	How Severe	How Frequent
1. Headaches or Migraines
2. Problems vision, hearing, taste, smell
3. Chest Pain or shortness of breath
4. Cough, wheezing or other breathing difficulties
5. Heartburn, gas, bloating, indigestion
6. Constipation, diarrhea, hemorrhoids
7. Urinary tract problems, stones,
infections in the bladder or kidney
8. Gynecologic problems(specify)
9. Infertility, impotence, low libido
10. Skin or hair problems
11. Bone or joint disorders, back pain
12. Neurological problems, fasciculations
13. Mood, emotion, or psychiatric problems
14. Fatigue, night sweats, lossof motivation

CONFIDENTIAL HEALTH QUESTIONNAIRE

BLOOD TEST INFO

CONTACT INFO

MEDICAL HISTORY

Clinical History And Presentation

(List all supplements on page 9)

Review of Systems (Check all that apply)

Please Indicate Past or Present Amounts

CHILDREN ONLY OR UNDER 25

WOMEN ONLY

DIET HISTORY

Family History

Review Of Systems

Supplements

Dietary History Form

History