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Name
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Full Address
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Email Address
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How often do you check your email?
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Monthly
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Work Phone
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Home Phone
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Cell Phone
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Age
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Height
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Current Weight
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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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Date of Birth
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Occupation
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How many hours do you work a week?
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Do you have any major health concerns?
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When was the last time you felt really vibrant and well?
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Other current major life concerns?
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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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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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What is your blood type?
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A-
B+
B-
O+
O-
AB+
AB-
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Do you sleep well?
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No
Other:
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How many hours do you sleep?
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How often do you wake up in the middle of the night?
Often
Sometimes
Rarely
Never
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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?
Constipation
Diarrhea
Gas
Distension
Belching
Bloating
Please explain your answer to the previous question in detail.
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How often do you have bowel movements?
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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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On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?
1
2
3
4
5
6
7
8
9
10
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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 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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