Clone of INTAKE FORM

Name

First NameLast Name

Email

beauty@life.com

Dates that you would like to receive the medicine

Date

Best Contact Number

Area CodePhone Number

Birth Date

MonthDayYear

Place of Birth

City and State

Birth Time

:HourMinutesAM/PM Option

Describe your top 3 complaints (Ex. depression, weight gain, spiritual connection, anger, trouble sleeping)

How many hours do you sleep on average per night?

What is the quality of your sleep?

Do you wake up often? Do you have trouble falling or staying asleep? Does the smallest movement or noise wake up you?

How many hours do you work everyday?

How many hours do you spend on technology everyday?

Computer, Phone, TV, Airpods

How many hours do you sleep on average per night?

How would you describe your current diet?

Do you follow any specific regimen? How much sugar, salt, processed food, food dyes are you currently eating?

What is your source of drinking water and how much do you drink daily?

Ex: 2 Liters daily of well water, spring water, tap water etc.

What previous surgeries or major health concerns have you had in the last 20 years?

Please share any health scares you may have experienced

Are you missing any organs?

(Tonsils, Appendix, Kidney, Gallbladder etc.)

Do you have any existing blood issues such as high blood pressure, blood clots etc?

Includes Anemia

Are you currently taking any pharmaceutical medications? (including birth control)

List the name and dosage if so, as well as how often you take it

What medicines or vaccines have you taken in the last year?

Include antibiotics

What synthetic chemicals or recreational drugs have you taken in the last 6 months?

Have you had seizures, concussions or serious brain/heart issues in the last 3 years? Please share details.

CEREBRAL Select the frequency of the symptom for each question. (0 = never, 4 = always)

Rows	0	1	2	3	4
1. Chronic high stress
2. Inability to handle stress
3. Decreased memory
4. Difficulty to focus
5. Increase in learning difficulty
6. Depression
7. Feeling hopeless, negative thoughts
8. Feeling overwhelmed, anxious for no reason
9. Anxiety
10. Sensitivity to noise

DIGESTION

Rows	0	1	2	3	4
1. Excess burping after meals
2. Burning in throat or stomach
3. Difficulty moving bowels
4. Diarrhea
5. Bad gas odor
6. Nausea
7. Hemorrhoids
8. Intestinal pain
9. Use of laxatives
10. Swelling

NEURO - MUSCULAR

Rows	0	1	2	3	4
1. Muscular weakness
2. Muscle spasms
3. Muscle pain
4. Pulsating pain in extremities
5. Strange sensations in skin
6. Weakness, loss of muscle control
7. Sciatica
8. Tremors
9. Uncontrolled spasms
10. Muscles always hurt

INFLAMMATION

Rows	0	1	2	3	4
1. Chronic joint pain
2. Headaches
3. Chronic constipation
4. Hypertension
5. Eczema or Psoriasis
6. Frequent allergies
7. High cholesterol
8. Rashes on hands or feet
9. Gallstones or gallbladder issues
10. Bitter taste in mouth in morning

CELLULAR ENERGY

Rows	0	1	2	3	4
1. Chronic anemia
2. Low body temperature
3. Dry Skin
4. Weight Gain
5. Constipation
6. Heart Palpitations
7. Difficulty falling/staying asleep
8. Fatigue
9. Craving sugar and sweets
10. Tired all the time

IMMUNOLOGICAL

Rows	0	1	2	3	4
1. Frequent diseases
2. Chronic sinusitis or infection
3. Chronic fatigue
4. History of use of antibiotics
5. Chronic candida / yeast infections
6. Inflammation of Tonsils
7. Diarrhea
8. Infection / fungus on toes
9. Dark circles / bags under eyes
10. Cold hands / feet

CIRCULATION

Rows	0	1	2	3	4
1. Abnormal / irregular pulse
2. Injuries heal slowly
3. Dizziness
4. Headaches
5. Chest pain
6. Abnormal blood pressure
7. Varicose veins
8. Tingling / numbing in extremities
9. Swollen ankles
10. Body is retaining water

HORMONAL

Rows	0	1	2	3	4
1. Difficulty getting out of bed
2. Dizzy when getting up
3. Thirsty all the time
4. Ringing in ears (high or low tones)
5. Acne
6. Dizziness
7. Hair loss
8. Constant Sweating
9. Frequent Urination

MEN ONLY

Rows	0	1	2	3	4
1. Decreased Sex Drive
2. Lack of physical energy
3. Depression episodes
4. Difficult Urinating

WOMEN ONLY

Rows	0	1	2	3	4
1. Irregular Periods
2. Hot Flashes
3. Adult Acne
4. Hair thinning

Intake Form