Please complete the following information:

Personal Information

*First Name:	*Last Name:
*Gender:	Male Female
*Weight (lbs):	*Height (ft'in"):
*Birth Date:
*Email:
*Body type:

Health History

Section A: General Questions

Do you have any serious allergies to medications or natural medicines?
If yes, what?
Previous Hospitalizations please list any with reason and dates:

Current prescription medications:

Current supplements:

Section B: Head

Do you have Headaches?
If yes, how often?      What kind?
Do you have dizziness or vertigo?
If yes, when does it happen?
Do you have frequent sinusitis?
If yes, how often?
Do you have to take antibiotics to clear the infection?
Do you have allergies? If yes, to what?
Seasonal Which season?
Environmental What Environmental?
Foods What kind?

Tinnitis or ringing in the ears?
Do you have frequent ear infections?
If yes, do you or did you use antibiotics to clear the infection?
Do you have eye infections?    If yes, what kinds?
Throat infections, tonsillitis or sore throats?
If yes, how often?
Bleeding gums? Do you ever get mouth sores or canker sores?
Do you tend to have a coating on your tongue?
If yes, what color?
Do you tend to have halitosis or bad breath?
Do you have dental cavities? If yes, how often?

Section C: Chest

Heart arythmias?
Heart palpitations? If yes, how often?
When, please describe if there is a certain trigger or time of day
Congestive heart failure? History of Mitrocardiac infarction?
History of cardiac surgery?
If yes, why?
Difficulty breathing or shortness of breath?
If yes, when?
Asthma or other restrictive airway disorder?

Section D: Digestion

Frequent erructations (burping)? If yes, when? Frequent flatulence?
How often do you have a bowel movement?
What is the average consistency of you bowel movement?
Stool quality:
I can see undigested food in my stool.
My stool floats?
My stool is very light colored and almost gray?
Hemorrhoids? Appetite?
Heartburn or GERD? Ulcers in stomach or small intestine?

Section E: Urinary System

Frequent bladder infections? Difficulty holding urine (when standing or laughing etc)? Difficulty voiding urine? History of urinary stones?
How often do you urinate?
What color is your urine?
Do you every see blood in your urine? Do you have pain with urination?

Section F: Musculoskelatal System

Do you have achy joints?
If yes, is it limited to:
Have you been diagnosed with Rheumatiod arthritis? Have you been diagnosed with osteo-arthritis? Have you had a hip replacement or knee surgery? Do you ever suffer from back pain? Have you ever had back surgery? Have you ever been diagnosed with bulging discs? Do you suffer from sciatic pain? Do you have frequent muscle cramps?

Section G: Skin

Do you have dry skin? Do you have eczema or psoriasis? Have you ever been diagnosed with melanoma? Have you ever had benign lesions removed from you skin? Do you freckle or burn in the sun easily? Do you have dandruff? Do you get skin rashes easily? Do you have any other kind of skin condition?
Please list:

Section H: Mental Emotional

Do you ever have difficulty remembering words, people or stories? Do you have any family history of Dementia or Alzhiemers? Do you get depressed easily? Do you cry frequently? Do you get angry or agitated easily? Do you feel melancholy often? Do you worry frequently? Would your friends describe you as happy? Are under a lot of stress on a daily basis? Do you care take for a relative or elderly/disabled person?

Section I: Immune Health

How often do you have a cold or flu?
How often do you urinate?
Do you have any autoimmune diseases?
If yes, what kind?
Do you have any type of cancer or have you had cancer in the past?
If yes, when?
and what kind?
Do you currently have cancer? If yes, what kind?
Do you have any chronic viral infections such as HPV, Herpes type I or II, or another virus? If yes, what is the virus?

Section J: Men Health

Do you ever have any problems urinating? If yes do you have pain with urination? Do you have burning with urination? Do you have difficulty urinating completely?

Section K: Women Health

Are you menstruating?
Is your menses?
Do you have any PMS type symptoms such as?
Cramping Breast tenderness Irritability Bloating
If no when was your last date of menstruation?
Do you have night sweats? If yes how often?
Do you have hot flashes? If yes, are they?
Have you been diagnosed with osteoporosis? Have you been diagnosed with osteopenia? Do you ten toward anemia? Have you had problems with infertility? Do you now or have you ever taken birth control pill? For how long? yrs

Section L: Environmental

How often do you drink alcohol?
What kind of alcohol do you usually drink?
Do you work around pesticide sprays or house cleaners or other chemicals through the day?
If yes, what are the chemicals?
Do you drink filtered water?
How many glasses or water do you drik each day?
How often do you exercise?

Section M: Diet

Do you eat three meals a day? Do you eat every two hours? How many servings of fruit do you eat each day?
How many servings of vegetables do you eat each day?
Do you prepare your own food at home? Do you go out for most of your meals? Do you drink soda? Do you drink coffee? If yes do you use sugar to sweeten it?
Do you eat meat (red meat, chicken or turkey)?
If yes do you eat it
Do you have any food allergies or sensitivities that you know?
If yes please list

Section N: Detoxification

Have you ever done a detox program? If yes which one?
For how many days
What was your experience, please describe: