Today's Date
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Month
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Day
Year
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Your Name:
First Name
Last Name
Cell Phone Number
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Area Code
Phone Number
Home Phone Number
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Area Code
Phone Number
Date Of Birth
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Month
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Day
Year
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Height
Weight
Email
Are You Married or Do You Live With Your Partner? If Yes..For How Long?
Do You Have Children? If Yes...Age & Name of Children
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What is Your Occupation? If Yes, What Day's and Hours Do You Work?
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Hobbies - Passions - Interests
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Please List All Major Health Concerns and Symptoms In Order of Importance. You Can List as many as you need to.
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What major life events have occurred in the last 3 years?
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Have you been under any more stress than "usual" in the last 3 years? And, if "yes" what?
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What things do you typically do that help you manage stress?
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Which Types of Doctors and Practitioners Have You Been To In The Past?
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Describe The Treatments They Gave You and Whether or Not They Were Effective?
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When Is The Last Time You Really Felt Good?
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Were You Healthy As A Child? If Not, Please List Any Health Problems You Can Remember Having, Especially If They Were Chronic and/or Recurring.
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Do you feel there was 1 or Multiple TRIGGER EVENT(s) that contributed or led to your current symptoms/illness/diagnosis? If so, what were they?
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Have you ever been constipated? (less than 2 bowel movements daily) If so, for how long?
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Have you ever taken or done anything for constipation? (laxatives, enemas, etc.)
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Please list any and all surgeries you've had along with the Dates:
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Have you taken antibiotics more than 6 times in your life? What kinds of issues do you remember taking them for?
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Have you ever done any life-mapping strategies? If so, what have you done?
Do you have trouble falling asleep? If So when do you remember first having trouble?
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Do you have trouble staying asleep? If So when do you remember first having trouble?
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How do you feel when you first wake up? (well-rested, still tired, achy, nauseous, etc.)
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Please list ALL medications you are CURRENTLY taking, along with the dosage, how often, and for how long:
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What symptoms, if any, do you feel are side effects of the medications?
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Please List ALL Supplements you are currently taking, including the brand names, how much of each, and how often:
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How many alcoholic drinks do you have each day? Or the total for each week? What are your drinks of choice?
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How many caffeinated beverages do you drink and which ones do you drink, how many each day and what do you put in your drinks?
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Do you eat out during the week? If so, how many times a week and what do you usually eat?
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How many times a week do you work out? What exercises do you typically do? For how long do you workout?
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Please List the 10 Most Un-Healthy Foods (what you deem to be the worst) You Eat Each Day/Week. Please put the foods you feel guilty about eating (if any) or the ones that you know don't make you feel great. The more details the better. :)
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Please List the 10 Healthiest Foods You Eat Each Day/Week.
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Please List an Average Day's Meals and Drinks and What Time.
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What are Your Top Health Goals for the next 12 months?
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Please put anything else here that you want to tell me or talk about when we speak.
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