Full Name: Email Address: Phone: Address: City: State: Zip:
Main reason for contact?
What gets in the way of your health and joy?
When do you feel the best/the worst?
List other doctors you have seen for your major health issues? List their diagnosis/treatments:
What has worked to improve your issues? What has not?
Please list history of surgeries, diagnosis, and dates:
Please list history of accidents:
What has been the most severe or on-going stress in your life?
Family health history (Including siblings):
Do you feel better or worse after you eat?
How is your digestive health?
How well do you sleep? How many hours?
How do you feel when waking up? Do you have energy during the day?
Best time of day? Worst Time of day? Why?
What important dreams have you manifested? What dreams have not come true?
What did you eat yesterday (all day, food, snacks, beverages)?
What do you drink all day long? Sodas, etc - Type and amount?
How many alcoholic beverages a day? Type and amount?
If you were stranded on desert island and all food was equally nutritious, what food would you best love to have to eat to your hearts content?
Please list current medications, vitamins, herbs? Dose?
Please list medications in last year? How many rounds of antibiotics? Prednisone?
Please list allergies (food, drugs, seasonal)?
What was the most pivotal events in your life 6 months to 2 years before getting ill/showing symptoms?
Any other comments?
