PERSONAL INFORMATION Name*
First
Last
Address*
Email*
How often do you check it?*
Home phone*
Cell phone
Age*
Date of birth*
Place of birth
Height*
Current weight*
Weight 6 months ago
Weight 1 year ago
Would you like your weight to be different? If so, how?*
Relationship status*
Children*
Pets*
Occupation*
Hours at work per week*
PERSONAL HEALTH Please list 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, or surgeries? (Now, or in the past)
Do you sleep well?
How many hours?
Do you wake up at night? If so, why?
How is the health of your mother?
How is the health of your father?
What is your ancestry?
Blood type:
Any ongoing sources of inflammation (eg. eczema or skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
Constipation/diarrhea/gas?
Allergies or sensitivities?
WOMEN'S HEALTH Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
Birth control history:
Vaginal infections or reproductive concerns?
HEALTH INFORMATION CONTINUED 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 how long?
Any remarkable exposure to toxins (eg. current or childhood home, nearby industrial community, job hobbies, travel, pesticides, heavy metals)?
How is the general status of your dental health?
Any troubling dental work or history of dental/oral infections? Dentures? Root canals?
How many silver/mercury fillings do you have?
Other dental work/issues beyond basic cleanings?
On a scale of 1-10, 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, or therapies with which you are involved?
What are your primary hobbies?
What role do sports and exercise play in your life?
What was your general health and well-being as a child?
What foods did you eat as a child? Breakfast
Lunch
Dinner
Snacks
Liquids
What’s your food like these days? Breakfast
Lunch
Dinner
Snacks
Liquids
Do you have any food allergies or sensitivities?
What percentage of your food is home cooked?
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 any addictions?
Anything else you would like to share?
Please rate the frequency and severity of symptoms you have experienced over the past two years. HEAD Headache 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Faintness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Dizziness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Insomnia 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
NOSE Stuffy nose 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Sinus problems 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Hay fever 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Sneezing attacks 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Excessive mucus formation 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
MOUTH Chronic coughing 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Gagging or frequent need to clear throat 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Sore throat, hoarseness, or loss of voice 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Swollen or discolored tongue, gums, or lips 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Tooth ache or gum pain or new dental work 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Canker sores 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
SKIN Acne 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Hives or other allergic breakout 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Rash or persistently dry skin 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Hair loss 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Flushing or hot flashes 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Frequently feel cold 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Excessive sweating 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Part of body frequently feeling numb. Which? (Please describe below) 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
HEART Irregular or skipped heartbeat 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Rapid or pounding heartbeat 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Chest pain 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
LUNGS Chest congestion 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Asthma, bronchitis 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Shortness of breath 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Difficulty breathing 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
DIGESTION Nausea or vomiting 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Diarrhea 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Constipation 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Bloated feeling 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Belching, burping 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Passing gas, flatulence 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Heartburn 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Intestinal or stomach pain. Which? (Please describe below) 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Other pain in GI tract? Where? (Please describe below) 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
JOINTS AND MUSCLES Pain or aches in joints 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Arthritis 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Stiffness or limitation of movement 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Pain or aches in muscles 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Tremor or restless leg 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Feeling of weakness or tiredness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
WEIGHT Binge eating/drinking 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Craving certain foods 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Excessive weight 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Compulsive eating 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Water retention 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Underweight 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
ENERGY Fatigue, sluggishness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Apathy, lethargy 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Hyperactivity 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Restlessness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
MIND Poor memory 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Confusion, poor comprehension 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Poor concentration or focus 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Poor physical coordination 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Difficulty in making decisions 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Stuttering or stammering 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Learning disabilities 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
MOOD Mood swings 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Anxiety, fear, nervousness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Anger, irritability, aggressiveness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Depression 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Other mood challenges? (Please describe below) 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
OTHER Frequent illness 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Frequent or urgent urination 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Inability to urinate or low urine flow 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Low libido or other sexual dysfunction 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Genital itch or discharge 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Women: breast fibroids 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Women: painful or tender breasts 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Women: Uterine/ovarian fibroids 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
Other (Please describe below) 0 - Never have the symptom 1 - Occasionally have it and the effect is Mild 2 - Occasionally have it and the effect is Severe 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe
Comments or details?
