Address:

                City:                            State:                  Zip:

 

Phone: home:                         Cell:                    Other:

 

Email:

 

Age:               Birthdate:

 

Occupation:                                                     Work hours:

 

Height:                Weight:              Desired Weight:

 

HEALTH HISTORY

 please indicate any: 

 

Current or past medical conditions:

 

 

RX medications you take:

 

 

OTC medications you take:

 

 

 Past surgeries:

 

 

 Serious accidents or injuries:

 

 

 Medical tests or treatments at this time:

 

 

Alternative treatments: acupuncture, chiropractic, massage, physical therapy, energy work, counseling, other:

 

 

Regular exercise: walking, running, swimming, hiking, biking, treadmill, stair climber, ellipitical, yoga, pilates, weights:

 

 

Dietary supplements you take:name, brand, type, amount:

 

 

 

 

 

 

Source of supplements: professional advised, health food store, drugstore, grocery, discount, mail order, multilevel:

 

 

 Indicate any specific health concerns you have today:

 

Airborn allergies: grass, trees, dust, animals, dander,hair

 

 

Food or chemical sensitivity: known allergies to food or drugs

 

 

Blood sugar: diabetes,hypoglycemia, unstable blood sugar

 

 

Candida: any yeast  or fungal infections

 

Bacterial or viral infections: 

 

 

Skin problems:dry,oily,acne, psoriasis, eczema, wrinkles,spots

 

 

Hair or scalp:  dry, oily, dandruff, loss, gray, slow growing 

 

 

Blood pressure:  high or low or instable, on medications

 

 

Fluid retention: puffiness or swelling of hands, feet, face, eyes

 

 

Heart problems:  defects, heart attack, stroke, high blood fats

 

 

Poor circulation: feels too hot or too cold, cold hands & feet

 

 

Low thyroid: fatigue, low energy, weight gain/loss

 

 

Food cravings: carbs, fats,sugar, alcohol,salt, spicy, sour 

 

 

Appetite:frequent or sudden hunger, can't feel full, overeating

 

 

Digestive: gas, bloating. acid indigestion,nausea,reflux

 

 

Bladder: incontinence, urgency, burning, pain, infections

 

 

Bowel: cramps/spasms,constipation, loose stools, gas

 

 

Arthritis: joint pain or swelling, muscle or bone pain

 

 

Pain: headaches, back,neck,jaw,leg, arm,hand,foot, bone pain

 

 

Sleep problems:insomnia,wakes easily, not dreaming, am tired

 

 

Stress: very high, high, moderate, low, post - traumatic stress

 

 

Source of stress: family, career, relationship, health, other

 

 

Mental: depression, anxiety, panic, obsessions, fright, fears

 

 

Memory:  forgetful, absent minded, memory loss present/past

 

 

Concentration:  unfocused, distracted, learning disability

 

 

Vision :decline, cloudy, eye diseases, eye strain, tearing,glare

 

 

Female hormone issues: low libido, pms, infertility, peri-       menopause, menopause, taking female hormones now/past

 

 

Male hormones issues:low libido,low sperm,infertility,hair loss

 

 

Premature aging: feel older, dry skin, slow hair growth, hair loss,gray hair, cold, tired, sore, stiff, sagging skin,brown spots, thirsty,bone loss, bone spurs, depression, memory decline, elevated blood pressure, diabetes,poor exercise tolerance, weight gain in middle, easily gets sick, slow to recover, vision and hearing decline,slow digestion and elimination.

 

List any other problems you are concerned with: