Please fill out the form below
*
Your Name
*
Email
*
Phone
*
Form
Health History
*
Questions
Date
Address
City
State
Zip
How often do you
check email?
Work phone
Home phone
Cell phone
Age
Height
Date of birth
Place of birth
Current weight
Weight six
months ago
one year ago
Would you like
your weight to
be different?
Yes
No
If so what?
Relationship status
Children?
Occupation
How many hours a week do you work?
Do you sleep well?
Yes
No
Do you wake up
at nights?
Yes
No
What time(s)
To urinate
What time do you generally get up
in the morning
Do you experience constipation / diarrhea
Yes
No
If yes, please
explain
WOMEN:
What blood type
are you
What is your ancestry
Are your
periods regular?
Yes
No
How many days
is your flow?
How frequent?
Painful or symptomatic
Yes
No
Please explain
Do you take any supplements or medications?
If so, which?
Are there any healers, helpers or therapies with
which you are involved? Please list
What role does exercise play in
your life?
Do you drink
coffee, smoke cigarettes, or have any major addictions?
What percentage
of your food is home cooked?
Where do you get the rest from?
Serious illness / hospitalizations / injury
How is the health
of your mother?
How is the health of your father?
What is your
chief concern?
Other concerns?
*
Are you human?
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