Cell Phone Number
Home Phone Number
Date Of Birth
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.
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?
Please list any and all surgeries you've had along with the Dates:
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 tested for Heavy Metals?
Have you ever been tested for Parasites?
Have you ever had your vitamin, mineral and enzyme levels tested?
Do you have any surgical implants/devices of any kind? If so, what are they?
Do you have trouble falling asleep?
Do you have trouble Staying Asleep?
When do you remember first start having trouble sleeping?
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 where do you usually go?
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 everything you eat on an average day, the more details you can give, the better. Breakfast, lunch, dinner, snacks, drinks, shakes, juices, protein shakes, protein bars, etc.
Please tell me the Top 5 Things you love MOST about your life.
What are Your Top Health Goals this year?
Please put anything else here that you want to tell me or talk about when we speak.
Enter the message as it's shown
Should be Empty: