Lifestyle & Medical History

Perscriptions

Anti-depressants

Anti-viral

Antibiotic use over the course of your life

Medical(General History)

Rows	Notes & Comments
Are you under a physicians care?
Have you had a serious illness?
Have you had a serious surgery?
Have you had anything surgically removed(ie. tonsils, gallbladder)?
have you had anything surgically added(ie. implants)?
Did you receive general vaccines as a child?
Did you have any adverse vaccine reactions?
How long has it been since you felt your best?
If you have chronic pain, please explain
When is your energy best during the day?
When is your energy worst during the day?

Diagnosed Cancer

Rows	Notes & Comments
Have you ever been diagnosed with cancer?
Chemotherapy duration
Radiation therapy duration

Women

Rows	Notes & Comments
Are your periods regular?
Are your periods 28 days?
Are you post-menopausal?
Are you currently pregnant?
Are you currently breastfeeding?
Are you currently trying to conceive?
Diagnosed infertility?

Covid History

Rows	Notes & Comments
Have you had COVID?
Do you have any lingering COVID symptoms?
Are you experiencing long haul COVID?
What is your COVID vaccination status?

Rows	0	1	2	3	4	5
Eats processed foods
Eats organic fruits & vegetables
Eats grass-fed/free range meats & poultry
Follows a vegan diet
Follows a vegetarian diet
Follows a low carb diet
Follows a keto diet
Follows a paleo diet
Drinks tap water
Drinks filtered water
Follows a low fat diet
Follows a restricted calorie diet
Prepares meals at home
Eats meals at restaurants
Eats fast food
Eats processed sugar
Eats dairy products
Eats grains other than wheat
Eats wheat
Foods cause adverse reactions
Eats prepackaged meals from the grocery store
Drinks coffee
Drinks tea
Drinks smoothies/beverages with juiced fruits/veggies
Drinking water comes from well
Drinks alcohol
Drinks soda or other beverages with sugar

Rows	0	1	2	3	4	5
Bed time between 9 & 11 pm
Wake up between 6-7 am
Keep late night hours, is in bed after 10 pm
Sleep less than 7-8 hours a night
Consistent sleep hygiene practices
Sleep in a dark bedroom
Electronics in the bedroom
Wireless router stays on at night
Your bed or anything on your bed plugs into an outlet
Sleep in a cool room

Rows	0	1	2	3	4	5
Recreational drug use
Vape use
Drug abuse
Alcohol abuse
Caffeine abuse
Job requires repetitive motion
No down time during the day
Tobacco use
Work overnight shifts
Intense physical labor
Dehydrated
Work shift lasts longer than 12 hours
Do you have pets?

Rows	0	1	2	3	4	5
Chronic unrelenting stress in daily life
Financial stress
Relationship stress
Familial stress
Over scheduled/extremely busy lifestyle
Job stress
Loss of a loved one
Loss of a relationship
Feel worried/unable to relax
Can't stop thinking
Type A personality
Workaholic
Mental strain for prolonged periods daily
Takes no time for self care
Acute stress/crisis present
Acute stress/crisis past
Experienced long periods of stress/trauma that affected my well being
Experienced one or more stressful events that affected my well being
Job or schooling requires concept shifting
Academic pressures
Frequently return to stressful memories
Meditation is a consistent part of my life
Caregiver for a loved one
Job requires emotional labor
Long work commute

Rows	0	1	2	3	4	5
EMF exposure at home
EMF exposure at work
Live in apartment or condominium
Mold exposure at work
Mold exposure at home
Live in an area with smog or air pollution
Exposure to chemicals in home(cleaners, personal care products)
Exposure to chemicals at work
Exposure to secondhand smoke
Noisy environment at home or work
Daily prolonged exposure to screens, TV, tablets, cell phone
Frequent air travel
Inadequate light
Have you travelled outside of your home country recently?

Rows	0	1	2	3	4	5
Routinely take supplements
Tolerance for supplements
Willingness & ability to budget money for supplements
Supplements are a consistent part of my routine
Specific supplements work well for me
Specific supplements don't work well for me

Rows	0	1	2	3	4	5
Head, neck or spinal injuries
Sports injuries
Concussions or other brain injuries
Broken bones
Whiplash
Serious car accident
Equestrian injuries
Participated in sports, martial arts, gymnastics or dance

Rows	0	1	2	3	4	5
Dental surgeries
Root canals
Metal fillings
Swollen or bleeding gums
Problems making saliva
Teeth extracted
Wear braces or dental splint
TMJ or other jaw issues
Quality of your daily oral hygiene