Please note, prior to your appointment make sure to do the following:
Congratulations on taking this step towards better health!
Patient Name *
Patient Birth Date *
Patient Gender *
Height/Weight *
Patient E-Mail *
What health care providers are you currently under the care of? *
Primary reason for making an appointment/ your goals *
What are your main health concerns in order of importance to you? *
Please list any food allergies, sensitivities or avoidances
Do you follow a particular eating plan?
Please list any environmental, chemical, or drug allergies
Do you currently experience any of the following?
Any major illnesses, surgeries, etc.?
Please list any recent stressful events
Please list your current medications and nutritional supplements, and how long you have been taking them
Exercise
Do you use recreational drugs?
Alcohol Consumption
Caffeine Consumption
Do you smoke?
Do you consume the following?
Have you ever been on antibiotics?
Are you exposed to chemicals in your home or workplace?
Do you work or live in an environment that has mold or a musty smell?
How would you rate your stress level overall on a scale of 1-10, for work, home life, health issues, etc? Please explain
What do you do for stress relief/management and self-care? How often?
On a scale of 1-10, what is your current energy level?
How many hours of sleep per night do you get? What time do you go to bed and wake up? Do you have any issues with falling or staying asleep? Why do you wake up if so?
Do you have healthy relationships and social/family connections?
Please list any emotional or physical traumas you have experienced, and what age (optional, please answer only if you choose to)
Do you feel like you are in control of your life, and you have the ability to heal?
If you could write yourself an RX for your best life, what would it be?
Include other comments regarding your Medical History
