The Biosanctuary Medical History & Health Goals Intake Form
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Date *
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First Name *
Last Name *
DOB *
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Height and weight? *
Phone Number *
Email address *
Physical Address *
Have you been COVID 19 vaccinated? 
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What are your health goals (mental and / physical) *
What health issues do you currently have? (mental and / physical) *
Have you had any lab testing done in the last year? If so, what were they and what were you results?
Please provide a comprehensive list of mental and physical symptoms you may suffer? How long? *
What previous health issues have you had? (mental and / physical) *
Are you in pain? Where and for how long? Cause? *
Do you suffer morning stiffness - enhanced joint pain?
Do you have amalgam / mercury fillings? *
Required
Do suffer Biotoxin Illness? Biotoxin Illness is mold, yeast, fungus, bacterial dysbiosis, SIBO...  If so, please explain *
Do you have inflammation, if so, where and how long? *
Brain / Focus Health. Please be thorough with this response. Do you suffer brain fog, inability to focus, retention problems, memory loss? *
How is your mental health? Anxiety, worry, panic, mood swings? *
Please list psychiatric drug prescriptions? and how long you've been on them. *
What is your general diet? *
Do you practice recreational drug use? If so, which ones?
Have you had Sacred Medicine Ceremonies? If so, when and which one/s?
Do you have any allergies? *
Please provide any additional information that you feel is important that we know about you *
How is your neuroendocrine / hormonal health?
How is your joint / connective tissue health?
How is your stomach and digestive health? Gas/indigestion?
Do you have difficulty swallowing?
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Do you consider yourself a "keyed up" person?
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Are your joints stiff when you wake up? 
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Do you have morning inflammation
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Do you get muscle cramps?
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Does your heart ever race?
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Do you experience frequent constipation?
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Do you get shaky if you get hungry and can't eat?
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Do you get shaky if you get hungry and can't eat?
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Do you have bad breath / halitosis? 
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Any injuries? 
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Do you experience headaches?
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Do you wake up to urinate during the night?
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Diet - Most Common Foods
Diet - Favorite Foods
How are your meals at home prepared?
Which grains do you consume?
Do you consume white flour products?
How much sugar do you consume weekly?
How much coffee do you consume daily?
List all artificial sweeteners you use
How many soft drinks do you consume weekly 
Do you consume high fructose corn syrup?
How much water do you drink daily
Do you consume GMOs?
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Do you use a microwave?
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What do you do for recreation?
What do you do for personal enrichment?
Are you spiritual?
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What do you do for exercise?
What is your super power? *
What does your optimal life look like?
How are you in service to humanity? What do you do for others? Charities? Nothing is too big or small!
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