Name:
Date:
Street:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Birthday:
Age:
An important question for you - your thoughts will help me understand where you are now, where you would like to be, your goals, and your purpose of this visit: Imagine feeling fully alive - in spirit, soul, and body. What would that look like for you?
What are your top 4 health concerns, listed in order of importance?
Relaxation: Do you set aside time daily to meditate/pray/sit quietly?
Relaxation: Do you set time in your day or week to rest and relax?
Relaxation: How often do you take a vacation?
Energy: How is your energy throughout the day?
Energy: Do you typically have a low energy time during the day?
If so, When?
Miscellaneous: Are you under the care of any health care provider? If so, for what diagnosis or reason?
List any chronic illnesses that you have ever had and currently have:
List any surgeries you have ever had:
List any scars that you have:
List any known allergies:
How often do you exercise in a week? What activities do you do?
How does your body heal from infections?
Childhood: Please describe your birth:(C-section, induced, forceps, suction, etc…)
Where you breast or bottle fed?
List any childhood illnesses that you had:
List any vaccinations you had as a child and as an adult:
Hydration: How much water do you drink in a day?
How much of these fluids do you consume in a day: Alcohol
Soda
Coffee
Tea
Dairy
Juice
Energy Drinks
Other
Diet: Briefly describe your diet (types of food, # of meals and snacks in a day):
Do you regularly skip meals in a day?
Please list any food cravings that you have: (salt or sugar):
Other:
Other:
Particular time that you wake up during the night?
Other:
How many hours do you sleep?
Sex: Describe any problems with sexual function/activity:
Skin: Describe any skin issues:
Stress: Please describe any emotional crises in the past year: (Death, divorce, job loss, change in family, pregnancy, school, friends, change in residences)
On a scale of 1 to 10 (10 = highest), what would your stress levels be in the following areas? In general?
Family?
Friends?
Co-workers?
Environment?
Health?
Work?
Spiritual?
Bowel Movements: Please checkable that apply:
1-3 bowel movements per day Fewer than one bowel movement per day Bowels are easily moved Pain, Strain, explosive, gas, or cramping Stools that are fairly large in diameter(the diameter of a colonies roughly 2-3 inches) Skinny stools Stools that hold together, Smooth on the outside, similar to the shape of a colon Rabbit pellets, diarrhea, chunky or lumpy stools (often can be a sign of dehydration of incomplete elimination) Brown in color Green, clay colored, red, black, or any color other than brown Bobbing stools Sinking or floating stools(this can be an indication of improper digestion of certain nutrients) Very little odor Bowel movements that have an overpowering Stench (another indication of incomplete or poor digestion)
Pain: Do you have pain anywhere? If yes, where and how often? When did it start?
On a scale of 0 (no pain) to 10 (worst pain you can imagine), how bad is it?
Supplements: Please list any supplements that you are currently taking:
Medications: Please list any medication that you are currently taking:
Please list anything else that you want me to know about you:
Please give me an idea of a typical day with food: (breakfast, lunch, dinner)
Please list your family history: like cancer, heart disease, diabetes, anything else?
Are they alive or deceased?
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