Health History FormPlease fill out our Health History Form to provide us more insight! After that, you will be taken automatically to our Symptom Questionnaire. Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * How often do you check your email? All the time Occasionally Rarely Never Preferred Phone Number * (###) ### #### Age Height Date of Birth MM DD YYYY Place of Birth Current Weight Weight six months ago Weight one year ago Would you like your weight to be different? If so, what? Occupation Hours Per Week Please list your major health concerns When was the last time you felt really vibrant and well? If you would 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? Blood Type Do you sleep well? How many hours? Wake up at night? Any reasons? Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)? The Following Section Is For Women Only Are your periods regular? How many days is your flow? How frequent? Painful or Symptomatic? Please Explain Birth Control History Vaginal infections, reproductive concerns? End of Women's Section Do you struggle with Constipation, Diarrhea, Gas, Distension, Belching, or Bloating? Please Explain In Detail. 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? 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)? 1 2 3 4 5 6 7 8 9 10 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 foods did you eat as a child? Please list as much as you can regarding Breakfast, Lunch, Dinner, Snacks, and Liquids. What foods do you eat now? Please list as much as you can regarding Breakfast, Lunch, Dinner, Snacks, and Liquids. Do you have any food allergies or sensitivities? What percentage of your food is home cooked? What percentage is not? Where do you get the rest from? If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly. Do you crave sugar, carbs, alcohol, coffee, cigarettes, other foods, or have any addictions? Anything else you would like to share? Click below to submit and you will be taken to a symptom questionnaire. Thank you!
