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? How many Days/Hours Do You Work Per Week?
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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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Please List any major life events that have occurred in the last 5 years.
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Have you been under any more stress than "usual" in the last 3 years? And, if "yes" what do you believe are the causes?
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What do you do to help you manage stress?
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Which Doctors and Practitioners Have You Been To For Your Health Issues?
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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? Which issues have you taken them for?
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Do you have trouble falling asleep? When did this start?
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Do you have trouble staying asleep? When did this start?
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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 per week? What are your drinks of choice? Do you feel like you are addicted? Do you want to stop?
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Which recreational drugs do you use, if any? For How Long have you been using and how often? Do you feel like you are addicted? Do you want to stop?
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How many caffeinated beverages do you drink and which ones, how many each day? (Including soda) Do you feel like you are addicted to caffeine?
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If you eat out during the week, 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 and Drinks (what you deem to be the worst) that you Consume Each Day/Week. These are any foods that you feel guilty about eating 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 and Drinks That You Consume Each Day/Week.
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Please List an Average Day's Meals and Drinks. Breakfast, Lunch, Dinner, Snacks
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What are Your Top Health Goals for the next 12 months?
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Have you ever done any life-mapping strategies? If so, what have you done?
Please put anything else here that you want to tell me or talk about when we speak.
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