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Confidential Health History
Email address *
Name *
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Full Address *
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How often do you check your email? *
Contact Number *
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Age *
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Height *
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Date of Birth *
MM
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Current Weight *
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Approximate Weight 6 Months Ago *
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Approximate Weight 1 Year Ago *
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Would you like your weight to be different? If so, what would you like it to be? *
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Occupation *
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How many hours do you work peer week? *
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If you would wave a magic wand and change two things what would they be? *
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Any serious illness, hospitalization, injuries, and surgeries, either now or in your past? *
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Any serious illness, hospitalization, injuries, and surgeries, either now or in your past? *
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How is the health of your mother? (If deceased relay illness) *
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How is the health of your father? (If deceased relay illness) *
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What is your ancestry? *
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Do you know you blood type? If so, what is it? *
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Do you sleep well? *
How many hours of sleep do you get per night? *
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How often do you wake up in the middle of the night? *
What do you think is the reason for your sleeping problems (if any)? *
Your answer
What do you think is the reason for your sleeping problems (if any)? *
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Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)? *
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Do you struggle with any of the following? *
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Please explain your answer to the previous question in detail *
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Please list ALL supplements or medications you take (prescription or over-the-counter) and frequency. *
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Have you ever taken antibiotics more than a short course or two as a child? If so, when/how often? For what? And for how long? *
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Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)? *
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What is the general status of your dental/health care? *
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Any troubling dental work or history of dental/oral infections? Dentures? Root canals? *
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How many silver/mercury fillings do you have? *
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How many silver/mercury fillings do you have? *
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Have you had any other major dental work/issues beyond basic cleanings? *
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On a scale of 1 to 10, how would you rate your general energy level (1=lowest)? *
lowest
highest
To what do you attribute this energy level? *
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Any healers, helpers, pets or therapies with which you are involved? Please list: *
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What are your primary hobbies? *
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What role do sports and exercise play in your life? *
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What role do sports and exercise play in your life? *
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What do you do to relax? How often? *
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What was your general health and well-being as a child? *
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What is your gender? * *
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