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5' 8"
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5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7' 0"
Weight (lbs)
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Marital Status
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Your Health History
Check all that apply
Anger
Anorexia
Anxiety
Appendicitis
Arthritis
Asthma
Back Pain (Lower)
Bad Breath
Bladder / Urinary Disorders
Blood Pressure (High)
Blood Pressure (Low)
Blood Shot Eyes
Bottle-Fed
Breast-Fed
Bulimia
C-Section Birth
Calf Cramps (during the night)
Canker Sores
Cavities (multiple)
Carbohydrate or sweet cravings
Chronic Fatigue
Cold Extremities
Constipation
Diabetes
Diarrhea
Dizziness
Dry Skin
Excess Phlegm and Mucus
Excessive Colds & Flu
Fear
Gas
Hair thinning/loss (female)
Headaches
Heartburn
Heavy/Dull Feeling
Hemorrhoids
Hepatitis
Hot Flashes
Hunger (Excess)
Hyperacidity
Hyperthyroid
Hypothyroid
Inability to Concentrate
Indigestion
Inflammation
Insomnia
Intolerance to Heat
Intolerant to Cold/Damp
Memory Issues
Menopauses
Menstrual Cramps (Bad)
Muscle Stiffness
Neck, shoulder or back spasms
Overweight
Pain (muscle)
Period (Heavy)
PMS
Restless
Ringing in Ears
Seasonal Allergies
Sinus Congestion
Skin Rashes
Sleeping (Excessive)
Sleeping Trouble (fall asleep, wake up multiple times)
Sleeping Trouble (trouble falling asleep, racing mind)
Sore Throat
Ulcers
Vaginal Birth
Yeast
What is Your History of Antibiotic Use?
Fasting Glucose
Testosterone (Men)
Vitamin D Level
Thyroid Reading
T3
T4
TSH
Food/Environmental Allergies or Sensitivities
What foods do you dislike?
Number of alcoholic drinks per week
Number of cups of coffee per day
Number of sodas per day
Number of glasses of water per day
Exercise pattern per week
0 days
1-3 days
3-5 days
5-7 days
Type(s) of Exercise
Stress level at work from 1-10 (10 is the highest)
Stress level at home from 1-10 (10 is the highest)
List any supplementation you take including brand name, type and amount.
Do you take any medication? If so, please list.
Do you have cancer?
Yes
No
If you have cancer, please give the specific type (i.e. ER positive breast cancer). If you are doing chemotherapy, please give the specific drug used.
Please describe in detail any significant health changes or surgeries you have had in the last 10 years.
What is your goal for the appointment today?
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