Confidential Health History
Email address *
Full Name *
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Full Address *
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Email Address *
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How often do you check your email? *
Best Contact Phone Number - plus an alternative number *
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Current Age? *
Your answer
Date of Birth? *
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Place of Birth? *
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Current weight? *
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Weight 6 months ago? *
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Weight one year ago? *
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What would you like your weight to be, if different? *
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Relationship Status? *
Children? *
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What is your gender? *
Occupation? *
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How many hours per week do your work? *
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Do you enjoy what you do for work? *
Your answer
Please list your main health concerns? What brings you to seek help today? *
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When was the last time you felt really good? *
Your answer
What changed? and When? *
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Do you have any other major life concerns? *
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If you could wave a magic wand and change 2 things about your life right now, what exactly would they be? *
Your answer
Did you have any serious hospitalizations, injuries, and/or surgeries recently or in your past? *
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Is your Mother Living? How is her health? *
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If deceased, please share how and when she passed. *
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Is your Father Living? How is his health? *
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If deceased, please share how and when he passed *
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What is your Ancestry? *
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Do you sleep well? How many hours? Do you wake up at night? What wakes you up? *
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Do you currently have any ongoing sources of Innflamation (e.g. eczema, psoriasis, or other skin irritations, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)? *
Your answer
Do you struggle with any of the following: *
Please explain in detail if/how you struggle with any of the above *
Your answer
List ALL medications and supplements you take (prescription and over-the-counter) and frequency *
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Have you ever taken antibiotics more than a short course or two as a child? *
Your answer
If so, when/how often? for what? and for how long? *
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Have you had any exposure to toxins either currently or as a child? (nearby industrial community, job, hobbies, travel, pesticides, heavy metals)? *
Your answer
What is the general status of your dental health? *
Your answer
Do you have 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? *
Your answer
On a scale of 1-10 how would you rate your general energy level (1=lowest)? *
To what to you attribute this energy level? *
Your answer
Do you participate in any healers, helpers, pets, therapies, meditation? *
Your answer
What role do sports and exercise play in your daily life? *
Your answer
What do you do to relax? How often? *
Your answer
What was your general health and well-being as a child? *
Your answer
What foods did you typically eat often as a child? *
Your answer
Breakfast *
Your answer
Lunch *
Your answer
Dinner *
Your answer
Snacks *
Your answer
Liquids *
Your answer
What are your foods like these days? Does it differ? If so, explain: Breakfast? *
Your answer
Lunch *
Your answer
Dinner *
Your answer
Snacks *
Your answer
Liquids *
Your answer
Do you have any "known" food allergies or sensitivities? *
Your answer
What percentage of your food is home-cooked? What percent is not? Where do you get the rest from? *
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If you have a general philosophy mindset or approach you use when choosing foods, please describe *
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Do you crave any of the following? *
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