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Name:________________________________________

Address: _______________________________                 City, State, Zip _______________________________

Home Phone: __________________

Cell Phone: __________________

E-Mail: ______________________________________

Preferred Method of Contact   (circle one)

Home Phone Cell Phone Email

Who referred you?  How did you hear about us?        Name: _____________________     

Your vitals:

Birthdate:_______ Gender:    M   F       Height:________     Weight:____________    Blood Pressure (if known):_____ Occupation:____________         

Why are you here???  What are your goals?

1.  ___________________________________________________  How long?  _____________________

2.  ___________________________________________________  How long?  _____________________

3.  ___________________________________________________  How long?  _____________________

4.  ___________________________________________________  How long?  _____________________

5.  ___________________________________________________  How long?  _____________________

Overall Health

Are you presently taking any medications or supplements and how long you have been taking them?  Please List. (Attach sheet if necessary)

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

DIET:  

What foods do you eat the most? _________________________________________________

List foods you crave. __________________________________________________

What kinds of fruits and vegetables do you like? _____________________________________________

Are you the first one done at dinner table?   Y N

Do you eat FAST FOOD? If so, how often? ___________

Do you eat more meat, carbs or veg/fruits? __________________________________________________

Do you drink pop/soda? Y   N   How often? __________________________________________________How much water do you drink per day? _________________Filtered?    Y    N

Please answer the following questions, be frank, no judgment here.  Yes or No (Circle one)

  1. If you’re feeling down, does a snack make you feel better?    Y N
  2. When you miss a meal, do you get cranky until you get food?    Y N
  3. Do you have a hard time going to sleep without a bedtime snack?    Y N
  4. Do you get tired and/or hungry in the mid-afternoon?     Y N
  5. Do you get sleepy, almost “drugged” feeling after eating bread, pasta or dessert?    Y N
  6. Do you think that now and then you’re a secret eater?     Y N
  7. Do you experience cravings for sugar, breads, pasta and baked goods?     Y N
  8. Do you feel shaky if you do not eat on time or have a snack?     Y       N
  9. Do you often find yourself irritable or angry?     Y       N
  10. How many bowel movements do you have in a day? _________  Color?  __________ Texture? ____________
  11. Do you have pain or burning with urination?     Y     N
  12. Do you have any fears or anxieties?     Y      N  ______________________________________________
  13. Are you missing any internal organs?    Y     N    Please list: ________________________________________
  14. Do you take antacids (for reflux or indigestion)?    Y     N
  15. Do you have any allergies?    Y    N
  16. What foods give you a tummy ache? _______________________________________________
  17. What foods make you sleepy? ______________________________________________
  18. Do you have hair on the top of your toes?    Y     N
  19. Have you been on or are you on hormone replacement therapy?   YES NO

Men:

  1. Do you struggle with the physical needs of sex?    Y    N
  2. Do you have pain during urination?     Y     N
  3. Do you have blood in your stool or urine?     Y     N
  4. Do you have any prostate issues you know about?   Y    N   Explain______________________________________________________________________________________

Women:

  1. How are your cycles? ______________________________________________________________________________
  2. Are you, or have you ever been on birth control?   Y    N   Fertility Treatments?   Y    N

If yes, give details: ________________________________________________________________________________

            Are you trying to get pregnant?      Y     N

  1. Have you ever had miscarriages or stillbirths?    Y     N
  2. Do you have any reproductive issues you are aware of?  __________________________________________ 
  3. Is your libido ok??  ____________________

Stress:  

  1. How do you deal with stress? ______________________________________________________________________  
  2. What is your main source of stress? _____________________________________________ 
  3. Are there times in the day that you feel your best? _________________ your worst?_________________
  4. Are you happy in your life right now?   Y    N
  5. Have you experienced any trauma in your past?  Y      N

Check the ones that apply to you:

Brittle nails
Hypotension
Cold hands and feet
Inability to concentrate
Cold intolerance
Infertility
Constipation
Irritability
Depression
Menstrual irregularities
Difficulty Swallowing
Muscle Cramps
Dry Skin
Muscle Weakness
Elevated Cholesterol
Nervousness
Hypertension (unknown cause)
Poor Memory
Eyelid swelling
Puffy Eyes
Fatigue
Slower Heartbeat
Hair Loss
Throat Pain
Hoarsness
Medication for anemia
Chemotherapy or radiation
Eat soy products (directly or in processed foods)
Fatigue
Sweating
Goiter
Tremor
Heat intolerance
Weakness
Hyperactivity
Weight loss (unexplained)
Wandering or spotty arrhythmia (P)
Insomnia  (P, T)
Menstrual disturbance
Wake up frequently  (P)
Nervousness
Spinal Disk Problems (P)
Palpitations
Sexual Dysfunction (P)
Depression (severe sudden onset) (P)
Sudden on set bi-polar (P)
Cardiomyopathy (P)


Memory loss
Emotional Tantrums
Joint Pain
Flu symptoms
Rashes
Swollen Lymph – for a long time
Eye inflammation (red and sore) – not itchy
Extreme fatigue
Heart Palpatations
Hepatitis
Bell’s Palsy
Erythema Migrans
Red earlobes
Neck & Back Pain
TMJ


Dental History:

Have you had any root canals?     Y   N Periodontal Disease?  Y N

Do you have any amalgam fillings?    Y N Have you had any removed?  Y N

Have you received any of the following diagnosis from a medical doctor?  

Chronic Fatigue
Multiple Sclerosis (P)
Crohn’s
Polymyalgia Rhemutica
Fibromyalgia
Polymyositis
PTSD
Psoriatic Arthritis
Grave’s Disease
Reiter’s
Hashimotos
Rheumatoid Arthritis
Juvenile Arthritis
Scleroderma
Lupus
Sjogrens
Ulcerative Colitis
Vasculitis
CMV
Herpes
Mono
Lyme’s Disease
Other:






Have you had any of the following that you are aware of – or do you suspect issues with any of these?

Brucella
Mycoplasm
Candida
Neisseria
Chlamydia
Parovirus B19
Coxiella
Staphylococcus Aureus
Fungi
Streptococcus
Hepatitis A/B/C
HIV
Other:
Other Viruses:  list below
Other:


Have you had any traumas such as:

Whiplash or Motor Vehicle Accident (esp. with air bag deployment)?  ____________

Concussion or head injury?  ___________

Serious fall where your head or neck may have been injured, damaged or thrown around?  ________

Mild to moderate blow to the head?  _______

Sexual abuse as a child?  -_________

Radiation exposure?   _________

Huffing or snorting drugs?  _______

Prolonged high stress??  ________

What diagnosis have you received in the past:

____________________________________________________________________________________________

____________________________________________________________________________________________

Health History

Do you presently, or in the past ever have any of the following conditions?  (Circle those that apply)

Anemia Frequent Headaches Chronic cold/flu symptoms Skin Conditions

Arthritis Heartburn Thyroid Condition Asthma Chest Pains Diabetes  

Depression Chronic Fatigue Osteoporosis Liver Problems Hypoglycemia

Kidney Problems High Cholesterol High Blood Pressure Unexplained Weight Changes

What was your childhood health and emotional experience like?  ____________________________________________________

Were you born c-section?    Yes No

Did you have antibiotics, anti-inflammatories, or immune suppressing medications? ______________________

Have you ever had eczema, psoriasis or any other Skin conditions? _______________________________

Surgeries, starting with most recent: __________________________________________________Hospitalizations:_________________________________________

__________________________________________________Hospitalizations:_________________________________________

__________________________________________________Hospitalizations:_________________________________________

Circle any of the following that have applies to you within the last 90 days:

Nauseous Bloating Heartburn Constipation     Belch after meals   Gas   Diarrhea

Bloated after meals     abdominal/intestinal pain     Travel outside US     Gurgles in Stomach

Alternate constipation/diarrhea      Stool compact/hard to pass     

Physical Body

How do you feel when you get up in morning? (Example, stiff)_______________________________________________

How many hours of sleep do you get on average? ____________________

       Do you get up in the night?  Y     N If yes – what time approximately?   __________

       For what reason?  _________________________Do your feet hurt a lot?    Y    N

Do you have difficulty concentrating?      Y       N    Do you feel fuzzy headed?    Y      N

Of this list, what changes are you willing to make to improve or get rid of your symptoms?

     Diet/Food Hydration              Exercise             Healthy Supplements         

Client Signature:_____________________________________________________Date:  _________________