Today's Date
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Month
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Day
Year
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
Height
Weight
Email
What is your heritage? (Eastern European, Italian, etc.)
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
What is Your Occupation? If Yes, What Day's and Hours Do You Work?
Hobbies - Passions - Interests
Please List All Major Health Concerns and Symptoms In Order of Importance. You Can List as many as you need to.
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?
Describe The Treatments They Gave You and Whether or Not They Were Effective?
When Is The Last Time You Really Felt Good?
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.
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?
Have you ever been constipated? (less than 2 bowel movements daily) If so, for how long?
Have you ever taken or done anything for constipation? (laxatives, enemas, etc.)
Have you ever been tested for Heavy Metals?
Have you ever been tested for Parasites?
Have you ever had your vitamin, mineral and enzyme levels tested?
Please list any and all surgeries you've had along with the Dates:
Do you have any surgical implants/devices of any kind? If so, what are they?
Have you taken antibiotics more than 6 times in your life? What kinds of issues do you remember taking them for?
If you are still menstruating, Is your Cycle Regular? (Every 26-30 days) If Yes, has it always been? If No, When did it start becoming irregular?
Do you have realtively few pre-menstrual symptoms that you consider not too bothersome? (minor bloating, tension) OR, do you have very troublesome pre-menstrual symptoms? If So, what are they?
Did you ever need to seek help for your pre-menstrual symptoms? If so, what did you do and/or take?
For Non-Menstruating Women: Did you have a relatively easy time going through Menopause? If so, what were your symptoms and how long did they last? If Not, how BAD were your symptoms, what were they and how long did they last?
Did you ever need to seek help for your Menopausal Symptoms? If so, what did you do and/or take?
Have you ever taken Birth Control Pills? If so, for how long?
Do you have trouble falling asleep? If So when do you remember first having trouble?
Do you have trouble staying asleep? If So when do you remember first having trouble?
How do you feel when you first wake up? (well-rested, still tired, achy, nauseous, etc.)
Please list ALL medications you are CURRENTLY taking, along with the dosage, how often, and for how long:
What symptoms, if any, do you feel are side effects of the medications?
Please List ALL Supplements you are currently taking, including the brand names, how much of each, and how often:
How many alcoholic drinks do you have each day? Or the total for each week? What are your drinks of choice?
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?
Do you eat out during the week? If so, how many times a week and what do you usually eat?
Do you eat nuts, seeds, beans and grains? If so, which ones and how often?
How many times a week do you work out? What exercises do you typically do? For how long do you workout?
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. :)
Please List the 10 Healthiest Foods You Eat Each Day/Week.
Please List an Average Day's Meals and Drinks and What Time.
What Packaged "Foods" do you typically have in your cupboards and what Brand Names are they? (Brand names are very important here) (Crackers, chips, snacks, bars, cookies, mac & cheese, pasta, etc.)
What Jars or Cans of "Food" do you have in your cupboards and what brands are they? (Brand names are very important here) (Soups, sauces,tuna, etc.)
What foods do you typically keep stocked in your Fridge and Freezer? (Dairy, frozen meals, meats, etc.)
Please tell me the Top 5 Things You Love MOST about Yourself. If there are more than 5 (there should be) please put them down as well! :)
What are Your Top Health Goals for the next 12 months?
What Dreams Do You Want To See Come To Fruition Before The End of This Year?
Please put anything else here that you want to tell me or talk about when we speak.
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