Health Information
Take five minutes to tell me some details about your health and family history. Then I can tailor my health advice to meet your specific needs!
Your Name *
Your answer
Email *
Your answer
Phone Number
Your answer
Age *
Your answer
Height
Your answer
Weight
Your answer
Health Concerns *
Listed in order of importance
Your answer
Family History
Does your family have a history of the following?
Check if "yes"
Social Habits
How much alcohol do you drink in a week?
Your answer
How many cigarettes do you smoke in a week?
Your answer
How often do you use laxatives?
Your answer
How many hours do you work in a week?
Your answer
How many hours do you sleep per night?
Your answer
Describe your exercise habits
How many times per week, types of exercise, etc.
Your answer
Eating Habits
What do you typically eat for breakfast?
Your answer
What do you typically eat for lunch?
Your answer
What do you typically eat for dinner?
Your answer
What do you snack on in between meals?
Your answer
Do you have any food sensitivities, intolerances, or allergies?
Your answer
How much fast food do you eat in a week?
Your answer
How much soda pop do you drink in a week?
Your answer
Are you on a low salt diet?
Your answer
Do you eat diet, sugar free, or light foods or drinks?
Your answer
What percentage of your food intake is organic?
Your answer
What sweets do you eat in a day?
Your answer
How much coffee do you drink per day?
Your answer
Do you eat until you are full at most meals?
Your answer
Do you eat breakfast every day?
Your answer
Do you prefer salty foods or sugary sweets?
Your answer
Adrenal Hypofunction
Check those that apply to you
Digestive Tract
Do you suffer from the following?
Check those that apply to you.
How many bowel movements do you have per day?
Your answer
Small Intestine
Check those that apply to you.
Gallbladder / Liver
Check those that apply to you.
Ears
Do you often get...
Emotions
Do you suffer from...
Eyes
Check those that apply.
Heart
Do you sometimes have...
Hypoglycemia
Check those that apply to you.
Hypothyroid
Hyperthyroid
Joint / Muscle
Do you suffer from...
Menstruation (females only)
Do you have...
During menses, do you have...
Are you experiencing peri-menopause?
Your answer
Menopausal
Skip this section if you are not experiencing menopause.
Do you suffer from...
How many years have you been menopausal?
Your answer
Mind
Do you suffer from...
Lungs
Do you get short of breath?
Your answer
Do you have asthma?
Your answer
Nose and Mouth
Do you suffer from...
Have you ever had amalgam(silver) filling? If so, do you still have them?
Your answer
Andropause (males only)
Do you suffer from...
Check those that apply.
Skin
Do you have...
Weight
Do you...
Are you under weight?
Your answer
Where do you retain your fat? (Belly, hips or...?)
Your answer
Environmental Toxins
Do you live in a new house, recently remodeled or repainted?
Your answer
Do you live near a cell phone tower or high-power lines?
Your answer
Have you been exposed to other toxins such as metals, pesticides, herbicides, or other?
Your answer
Other
From 1-10 how would you rate your stress?
Stress Free
Extremely Stressed
Describe any other ailments that you often suffer from, such as the common cold, flu, muscle aches, etc.
Your answer
Please list any results for tryglycerides, cholesterol, glucose, blood pressure and thyroid if done within the last 6 months.
Your answer
What have some other professionals told you about your health?
Your answer
What has your doctor diagnosed you with past or present?
Your answer
Have you had any operations, major accidents or injuries? What and when?
Your answer
Any unresolved physical or emotional trauma? If so, what?
Your answer
List any nutritional supplements you are currently taking including name brands and amounts?
Your answer
List any prescriptions or over the counter medications you are currently taking and for how long?
Your answer
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