How Healthy Do You Feel Form Name Phone Date Address Sex MaleFemale Newsletter YesNo Email Age Height Weight Blood Group Occupation Do you have a job? YesNo Are you generally happy with life? YesNo Age of Children Are you a caregiver for anyone else? YesNo DESCRIBE YOUR NORMAL DAYS OF EATING TO ME: Breakfast Lunch Dinner Snacks PLEASE DESCRIBE YOUR NORMAL DAYS OF FLUID INTAKE TO ME: Water (Filtered?) YesNo Alcohol YesNo Coffee/Tea YesNo Diet Soda YesNo Juice YesNo Milk YesNo Other How much sleep do you average? Is it Sound? YesNo What time do you waken? Do you wake to void? YesNo Do you have urgency? YesNo Describe your bowl routine to me X's Daily X's Weekly Consistancy Bleeding? YesNo Pain? YesNo Tell me about your energy level Do you feel stressed? YesNo Nervous YesNo What do you do when stressed? How would you describe yourself emotionally? Are you seeking an MD for anything? Surgical History List your current medications (Please include birth control & over the counter meds) HOW HEALTHY DO YOU FEEL? What supplements Do you take? Did you take them today? YesNo Do you exercise regulary? YesNo What supplements Do you take? Please check any of the following that give you problems with any regularity: Carb Digestion Airborne allergiesFood allergiesConstipationHeart weaknessRespiratory issuesDry tendenciesSore throatsStarch cravingsHeadachesWhereMouth sores Fat Digestion IndigestionDry, Itchy skinTired mid-afternoonSign frequentlyHigh cholestrolPainful ribs, NeckTight shouldersPMS sore breastsSore ribs after mealsDifficult to inhaleBleeding issues Protein Digestion Moist tendenciesDepressionKidney problemMenstrual concernsMenopause issuesStress incontinenceWater retentionBack problemReceding gumsTMJ sore jawsArthritis/joint pain Other Digestion Dizzy spellsBlood pressureBruisingMood swingsMuscle crampsIrritable if hungryNumb foot/headPerspire easilyEyes light sensitiveRinging in earsDo you smoke? Do you crave foods such as salty, crunchy, Chocolate, paenut butter, starches, alcohol, sweets? List other foods Why did you come here today? What is the most important issue you would like to have corrected? Is there anything else I would benefit from knowing about you or your situation?
