Name_________________________________________________Date________

E-Mail_______________________________ Occupation______________

Referred By__________________________ B-Day__________________

Age: Wt: Ht: BP:

What is your main complaint or area of interest?

________________________________________________________________

Family History (check all that apply):

Stroke_________________________ Diabetes________________________

High BP________________________ Weight Problems__________________

Depression_____________________ Ulcer____________________________

Heart Disease___________________ Psoriasis_________________________

Arthritis (RA or OA)_______________ Glaucoma________________________

Cancer___ Type?________________ Family Side: ♀__________♂_________

Personal History (check all that apply):

  • Arthritis
    • RA
    • OA
  • Stroke
  • High Cholesterol
    • How High?_______
  • High Blood Pressure
    • How High?_______
  • Diabetes
    • Metabolic Syndrome
    • Insulin Resistance
  • Low Blood Sugar
  • Chronic Fatigue
    • Fibromyalgia
    • Multiple Chemical Sensitivities
    • Infectious Mononucleosis
  • Frequent Colds/Flu
  • Herpes/ HPV
  • Cold Sores
  • Cancer
    • What type?_________
    • Chemo?____________
    • Rads?
    • Steroids?
  • Surgeries
    • What type?_________
  • Thyroid Problems
  • Hypothyroidism
  • Hyperthyroidism
  • Headaches
  • Chronic Tension
  • Migraines
  • Cluster
  • Hormonal
  • Food Allergies
  • To What?____________
  • Seasonal Allergies
  • To What?____________
  • Medication Allergies
  • To What?____________
  • Sleep Problems
  • Forgetfulness
  • Hot Flashes
  • PMS
  • Birth Control Pills/ Hormones
  • Weight Problems
  • Constipation
  • Diarrhea
  • Abdominal Cramping/ Bloating
  • Yeast Infections
  • Low Libido
  • Ulcers

          What Medications and Dosages are you taking? List all please:

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

What Vitamins and herbal supplements are you taking? List all please:

________________________________________________________________________________________________________________________________________________________________________

Do you eat, drink, or use (circle all that apply):

Antacids Protein Drinks Appetite Suppressants

Aspirin Alcohol Coffee

Tylenol Tap Water Decaf Coffee

Ibuprofen Bottled Water Diet Soda

Laxatives Tea Soda

Refined Sugars Candy White Bread

Margarine Butter Fast Foods

Chewing Gum Fried Foods Chips

Salt (w/out tasting) Tobacco Cigarettes

Artificial Sweeteners (Blue, Pink, Yellow) Coffee Creamers

List any food aversions and/or foods you dislike: _____________________________________________________________________________

Do you get noticeably irritated, weak, or lightheaded if you haven’t eaten in a while? ______________________________________________________________________________

Do you crave certain foods? _________ What foods?         Sweets?               Chocolate?              Bread/Pasta?       Fried Foods?          Alcoholic drinks?            Sodas/Diet Sodas?                  Meat?                   Other? ________________________________________________________________________

Are you:

Under excessive amounts of stress______ at home__________ at work___________

Physical Stress____________________ Mental Stress_______________________________

Exposed to chemicals regularly________ Type________________________________

Exposed to smoke regularly__________

How often do you have bowel movements? ______________per day/ week/ month

Urinate? _________ per day

How is your dental health? Prone to Cavities? Gum Disease? Bleeding Gums? ________________________________________________________________________________

Are your nails week or brittle?_______________________________________________________

Average Sleep per night? ___________________________________________________________

Any sleeping problems? ____________________________________________________________

To what extent will you commit to achieving better health?

Little_______    Moderate _______   Major________   Extreme_______

Is there anything else about either your history or your current condition that you feel is important to mention?

_______________________________________________________________________________________________________________________________________________________________________________________