General Info
Name
Street Address
City
State
Zip code
Email Address
How often do you check your email?
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Work Phone
Home Phone
Cell Phone
Age
Height
Date of Birth
MM
/
DD
/
YYYY
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different? If so, what would you like it to be?
Occupation
Hours per Week
Major Health Concerns
When was the last time you felt really vibrant and well?
Other current major life concerns?
If you could wave a magic wand and change two things what would they be?
Any serious illness, hospitalization, injuries, and surgeries, either now or in your past?
How is the health of your mother? (If deceased relay illness)
How is the health of your father? (If deceased relay illness)
What is your ancestry?
What is your blood type?
Do you sleep well?
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How many hours?
How often do you wake up in the middle of the night?
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What do you think is the reason for your sleeping problems (if any)?
Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
Do you struggle with any of the following?
Please explain your answer to the previous question in detail.
How often do you have bowel movements?
Please list ALL supplements or medications you take (prescription or over-the-counter) and frequency.
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?
Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?
What is the general status of your dental/health care?
Any troubling dental work or history of dental/oral infections? Dentures? Root canals?
How many silver/mercury fillings do you have?
Have you had any other major dental work/issues beyond basic cleanings?
On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?
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To what do you attribute this energy level?
Any healers, helpers, pets or therapies with which you are involved? Please list:
What are your primary hobbies?
What role do sports and exercise play in your life?
What do you do to relax? How often?
What was your general health and well-being as a child?
What is your gender? *
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