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Home
About
Services Offered
Wholistic Consultation
Living Well Shop
Herbal Tea Blends
Organic Dried Single Herbs
Wholistic Consultation Packages
HC Individualized Body Scan
HC Micro Circulation BEMER Therapy
HC Living Well Package
Holistic Marriage Ceremony
Whole Body Health
Elemental Support
Workshops
Contact
Crescent News
Rewards
Search
First Visit Client Information
*
Indicates required field
Name
*
First
Last
Telephone Number
*
Cell Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Occupation
*
Email
*
Birthday
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
01
02
03
04
05
06
07
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
Age
*
Gender
*
Male
Female
Birth Place
*
Marital Status
*
Single
Married
Divorced
Widowed
No. of children
*
I Hereby Attest To The Following Statement:
I acknowledge that the Nutritional Profile, Evaluation, and Suggested Nutritional program and any supplemental materials such as Vitamins, Minerals, Enzymes and Herbs are not for the “diagnosis”, treatment, cure, alleviation, prevention, or care of any “disease” of any kind, in any way. I agree that I am totally responsible for obtaining qualified medical assistance for any such services, or for the care of any “disease” or “pathological” condition. Nevertheless, I reserve myself the right to use the knowledge I gain from the consultation in any legal manner I may choose in the care of my own body. I further declare that the sole reason for requesting the services from this office is for obtaining a “Suggested Nutritional Program” for the building of my health and well-being.
I recognize that analysis is a revolutionary and unorthodox approach to health, and that it is based in Jesus Christ. Being of sound mind, I have chosen this method of building my health of my own free will and in exercise of my Constitutional Right of the attainment of life, liberty, and the pursuit of happiness. Consultations are limited to education in matters pertaining to the improvement in the overall health and physical fitness for maintenance of the best possible state of physical, mental and emotional health. These subjects may or may not include examination or urine and saliva. Such procedures are not for the diagnosis or treatment of any health condition or disease. Any procedures including fasting are at my own choice.
I am fully aware of the fact that the services being provided to me are spiritually oriented, and that those who counsel me have been educated in an alternative counseling discipline. I realize my God given rights and Constitutional rights, which allow me to seek the best care and education for my own personal needs. I am aware that I am entitled to receive information from my counselors about any method of procedures to be used, fees to be charged and the approximate length of procedure, if it can be determined by personal experience, testimonies and suggestions.
I am free to obtain a second opinion from another practitioner at any time I feel it necessary. I understand that all I say is to be kept confidential, and that information concerning myself can be released to another alternative health practitioner only with my signed consent.
I hereby grant, to my counselors to act in my behalf in matters concerning my health with alternative ways. I authorize them to perform any and all health services for me that I have a right to perform for myself and agree to hold them blameless for any and all such acts.
I am not representative of a branch of a municipal, state or U.S. government, the American Medical Association or the Federal Drug Administration.
I have read and fully understand the above listed information and I do hereby request that I be allowed to participate in a health consultation program for the following reasons:
Reason(s)
*
Personal Health History
GENERAL INFORMATION
1. Currently taking any medications?
*
Yes
No
If so, what medication?
*
2. Are you involved in any alternative/preventative care?
*
Yes
No
How long?
*
3. What is your main concern?
*
4. What are your goals for your health/life?
*
5. List any current symptoms or problems
*
6. What are (3) three factors in your life that seem most important to your daily health?
*
REVIEW OF SYSTEMS/SYMPTOMS
7. Mark a check by a symptom you have or have had in recent years. Put another check if the problem occurs often; and put another check if it is a regular difficulty.
Weight loss or gain
*
Had in recent year(s)
Often
Regular
Mucous Problems
*
Had in recent year(s)
Often
Regular
Hemorrhoids
*
Had in recent year(s)
Often
Regular
Fatigue
*
Had in recent year(s)
Often
Regular
Sores in Mouth
*
Had in recent year(s)
Often
Regular
Urinary Problems
*
Had in recent year(s)
Often
Regular
Confusion
*
Had in recent year(s)
Often
Regular
Tongue Problems
*
Had in recent year(s)
Often
Regular
Burning on Urination
*
Had in recent year(s)
Often
Regular
Nervousness
*
Had in recent year(s)
Often
Regular
Coated Tongue
*
Had in recent year(s)
Often
Regular
Bladder/Kidney Infection
*
Had in recent year(s)
Often
Regular
Muscle Tension
*
Had in recent year(s)
Often
Regular
Bad Breath
*
Had in recent year(s)
Often
Regular
Bedwetting
*
Had in recent year(s)
Often
Regular
Muscle Cramps
*
Had in recent year(s)
Often
Regular
Teeth/Gum Problems
*
Had in recent year(s)
Often
Regular
Blood in Urine
*
Had in recent year(s)
Often
Regular
Cold hands/feet
*
Had in recent year(s)
Often
Regular
Neck Pains
*
Had in recent year(s)
Often
Regular
Back Pains
*
Had in recent year(s)
Often
Regular
Itching
*
Had in recent year(s)
Often
Regular
Cough
*
Had in recent year(s)
Often
Regular
Leg Swelling
*
Had in recent year(s)
Often
Regular
Skin Rashes
*
Had in recent year(s)
Often
Regular
Difficulty Breathing
*
Had in recent year(s)
Often
Regular
Arm/Shoulder/Leg Problem
*
Had in recent year(s)
Often
Regular
Skin Boils
*
Had in recent year(s)
Often
Regular
Shortness of Breath
*
Had in recent year(s)
Often
Regular
Bone/Joints Pains
*
Had in recent year(s)
Often
Regular
Headaches
*
Had in recent year(s)
Often
Regular
Coughing Blood
*
Had in recent year(s)
Often
Regular
Joint Swellings
*
Had in recent year(s)
Often
Regular
Fevers
*
Had in recent year(s)
Often
Regular
Heart Palpitations
*
Had in recent year(s)
Often
Regular
Bruise Easily
*
Had in recent year(s)
Often
Regular
Nightmares
*
Had in recent year(s)
Often
Regular
Chest Pains
*
Had in recent year(s)
Often
Regular
Irregular Bowel Movements/Diarrhea
*
Had in recent year(s)
Often
Regular
Dizziness
*
Had in recent year(s)
Often
Regular
Breast Lumps/Pains
*
Had in recent year(s)
Often
Regular
Bloody/Black Bowel Movements
*
Had in recent year(s)
Often
Regular
Blackouts
*
Had in recent year(s)
Often
Regular
Poor Endurance
*
Had in recent year(s)
Often
Regular
Number of BM daily
*
Had in recent year(s)
Often
Regular
Ringing in Ears
*
Had in recent year(s)
Often
Regular
Gas
*
Had in recent year(s)
Often
Regular
Increases Sexual Desire
*
Had in recent year(s)
Often
Regular
Earaches
*
Had in recent year(s)
Often
Regular
Abdominal Pains
*
Had in recent year(s)
Often
Regular
Decreases Sexual Desire
*
Had in recent year(s)
Often
Regular
Double/Blurry/Vision
*
Had in recent year(s)
Often
Regular
Difficult Digestion
*
Had in recent year(s)
Often
Regular
Birth Control
*
Had in recent year(s)
Often
Regular
Eyestrain
*
Had in recent year(s)
Often
Regular
Constipation
*
Had in recent year(s)
Often
Regular
Aging Rapidly
*
Had in recent year(s)
Often
Regular
Nasal Congestion
*
Had in recent year(s)
Often
Regular
Sinus Pressure/Nose Bleeds
*
Had in recent year(s)
Often
Regular
PAST MEDICAL HISTORY
8. Do you have allergies?
*
Yes
No
Please specify:
*
9. If you have food allergies list which foods?
*
10. Do you take any regular medications, either prescribed or over the counter?
*
Yes
No
If yes, what and how often?
*
11. Do you take any regular vitamin, mineral or herbal supplements?
*
Yes
No
Please list:
*
12. Have you had any operations?
*
Yes
No
If yes what for and year occurred?
*
13. Any major injuries/accidents?
*
Yes
No
If so specify area of injury and date occurred:
*
14. Any major illness or hospitalizations?
*
Yes
No
Both
Specify illness/hospitalization and date:
*
15. Check any of these you have incurred. Write approximate year in the textbox below.
*
Pneumonia
High Blood Pressure
Kidney Infection
Tuberculosis
Low Blood Pressure
Parasites
Hepatitis
Heart Disease
Rheumatic Fever
Asthma
Heart Attack
Measles/German
Diabetes
Cancer
Measles/Regular
Hypoglycemia
Blood Transfusion
Mumps
Epilepsy
Migraine Headaches
Chicken Pox
Eczema
Ulcer
Polio
Skin Boils
Anemia
Whooping Cough
Kidney Stone
Arthritis
Diphtheria
Drug Reaction
Obesity
Colitis
Psoriasis
Mental Breakdown
Syphilis
Hives
Jaundice
Gonorrhea
Approximate year incurred
*
16. Do any of these illnesses run in the family?
*
Diabetes
Cancer
High Blood Pressure
Epilepsy
Heart Disease
Mental Illness
Tuberculosis
Thyroid Problems
Asthma
Obesity
Gout
Twins(not an illness)
DIET AND EXERCISE
17. How would you describe your appetite?
*
Good
Fair
In Between
Explain:
*
18. How would describe your eating habits?
*
Good
Fair
In Between
Explain:
*
19. How do you feel about the foods you eat?
*
20. Do you floss your teeth regularly?
*
Yes
No
21. Write the percentage in your diet of these food categories. Total 100
Fruits
*
Vegetables
*
Grains
*
Nuts, Beans, Seeds
*
Dairy
*
Meats
*
22. What percents of your diet is raw? Cooked? Total of 100%
Raw
*
Cooked
*
23. What percents of your diary food is raw? Pasteurized? Total of 100%
Raw
*
Pasteurized
*
24. List the percents of these meat categories, Total of 100%
Chicken
*
Fish
*
Beef
*
Other
*
25. Do you use foods made with chemicals additives or preservatives?
*
Yes
No
Please list which foods?
*
26. What percent of your food is from restaurants?
*
27. What percent of your food do you prepare yourself?
*
28. For the next categories, write the average number of times in a week these items are consumed in your diet. (e.g. 0= never, 2/w = twice weekly, 3/d = three times daily)
Fried foods
*
Alcohol
*
Beer
*
Wine
*
White/Brown Sugar
*
Drugs
*
Coffee
*
Nicotine
*
Liquor
*
Food Additives (chemicals)
*
29. Is there one or more particular food flavor that you crave? (Check all that applies)
*
Sweet
Salty
Spicy
Bitter
Sour
Other
Other food you crave
*
30. Do you have a garden?
*
Yes
No
If (yes) Check all that applies.
*
Vegetables
Flowers
Urban (rooftop, containers, balconies)
31. Do you enjoy exercise?
*
Yes
No
If (yes) is it Mild? or Strenuous?
*
Mild
Strenuous
How often do you exercise weekly?
*
32. Do you sweat easily?
*
Yes
No
If yes how often?
*
List exercise and frequency.
*
33. Do you have any pets?
*
Yes
No
What kind of pet/s?
*
GENERAL QUESTION
34. Are you able to express your emotions/feelings?
*
Yes
No
35. Are there any emotions you predominantly feel? (Check all that applies)
*
Anger
Sadness
Fear
Sympathy/Worry
Excessive Joy
Depression
Other
Other
*
36. How would you describe yourself emotional/unemotional?
*
37. What makes you nervous?
*
38. Do you typically have much stress in your life?
*
Yes
No
39. If so, what does it surround?
*
Family
Work
Finances
Relationships
Other
Other (briefly explain)
*
40. Do you sleep well?
*
Yes
No
How many hours a night?
*
41. Do you dream?
*
Yes
No
How often?
*
42. Do you remember any?
*
Yes
No
Are they helpful?
*
Yes
No
43. Are you happy with your general energy level?
*
Yes
No
If (NO) briefly explain
*
44. Is there a low point in your day?
*
Yes
No
If yes when?
*
45. Do you have a favorite time of day?
*
Yes
No
If yes when?
*
46. Do you have a favorite climate/weather?
*
Yes
No
What?
*
47. Are there climates you especially don’t like?
*
Yes
No
What and Why?
*
48. What is your favorites color(s)?
*
49. What is your favorite’s season?
*
50. What is your highest level of school you completed?
*
Elementary
High School
College
51. Any other organized life/trade training?
*
52. Do you have any military service?
*
Yes
No
If yes what branch?
*
53. With whom do you live?
*
Relationship
*
54. What is work profession?
*
55. What are your hobbies/pleasures?
*
56. What are your indulgences? How often?
*
57. Have you ever abstained from or “quit” anything?
*
Yes
No
What and Why? And for how long?
*
58. Do you ever crave that which you have curbed?
*
Yes
No
When?
*
59. How do you feel about yourself?
*
60. How do you feel about your life?
*
FOR WOMEN ONLY
1. Date of last menstrual period
*
2. Are your periods regular?
*
Yes
No
3. How many days is your flow?
*
4. Do you get any of the following during your Cycle? (Check all that applies)
*
Pains
Cramping
Blotting
Clotting
Cravings
Mood Swings
5. What color is your blood?
*
Bright Red
Dark Red
In Between
6. Have you ever had any yeast infection?
*
Yes
No
7. Do you practice Birth Control?
*
Yes
No
8. Number of pregnancies?
*
Deliveries
*
Abortions
*
Miscarriage(s)
*
Other
*
9. How many Children do you have?
Boys
*
Girls
*
10. Age of first Child
*
Age of last Child
*
11. Menopausal?
*
Yes
No
If yes, what are your symptoms?
*
12. Anything additional you would like to share?
*
HEALTH QUESTIONNAIRE
A SELF ASSESSMENT
PLEASE CHOOSE YES OR NO WHERE APPLICABLE AND ADD COMMENTS AS NECESSARY.
THYROID/PARATHYROID (Glandular System)
Do you get Cold hands and/or feet?
*
Yes
No
Is it easy to put on weight and hard to lose it?
*
Yes
No
Is your bladder strong or weak?
*
Yes
No
Do you have low energy levels?
*
Yes
No
Do you suffer from symptoms of depression?
*
Yes
No
Do you irritable easily?
*
Yes
No
Do you bruise easily?
*
Yes
No
Do you get cramping in your muscles?
*
Yes
No
Do you sweat?
*
Normally
Profusely
Hardly at all
Do you have an irregular heartbeat?
*
Yes
No
Do you have Mitral Valve Prolapse (Heart Murmur)?
*
Yes
No
Do you get headaches or migraines?
*
Yes
No
Have you ever had an aneurysm?
*
Yes
No
Do your lab tests comeback showing low calcium levels?
*
Yes
No
Did you score low on your bone density tests?
*
Yes
No
Do you have osteoporosis?
*
Yes
No
Do you have scoliosis?
*
Yes
No
Do you have spine deterioration or herniated discs?
*
Yes
No
Are your fingernails ridged, brittle or weak?
*
Yes
No
Do you have, or have you ever had, hemorrhoids or hernias?
*
Yes
No
Do you have any prolapsed organs?
*
Yes
No
Do you have varicose or spider veins?
*
Yes
No
Do your legs get tired or Cramp after you walk?
*
Yes
No
Have you been diagnosed with Hashimoto's or Reidel's thyroiditis? Has a family member?
*
Yes
No
PANCREAS
Do you see any undigested foods in your stools?
*
Yes
No
Do you feel your foods just sitting in your stomach?
*
Yes
No
Do you have acid reflux?
*
Yes
No
Do you get gas after you eat?
*
Yes
No
Are you thin and have a hard time putting on weight?
*
Yes
No
Do your foods pass right through you (diarrhea)?
*
Yes
No
Do you have moles on your body?
*
Yes
No
ADRENAL GLANDS (medulla) (Glandular System)
Are you overweight?
*
Yes
No
Do you have M.S., Parkinson's or Palsy?
*
Yes
No
If yes, please specify:
*
Do you feel excessive shyness or inferior to others?
*
Yes
No
Do you have anxiety attacks or feel overly anxious?
*
Yes
No
Do you have a hard time sleeping or insomnia? (pineal gland)
*
Yes
No
Do you have tremors, nervous legs, etc.?
*
Yes
No
Do you have tinnitus (ringing in the ears)?
*
Yes
No
Do you have hypoglycemia (low blood Sugar)?
*
Yes
No
Do you have diabetes (high blood sugar)?
*
Yes
No
If yes, Type I OR Type II D
*
Do you have heart arrhythmias?
*
Yes
No
Do you have shortness of breath?
*
Yes
No
Do you have Chronic Fatigue Syndrome?
*
Yes
No
Have you ever been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia?
*
Yes
No
ADRENAL GLANDS (cortex) (Glandular System)
Do you have elevated blood cholesterol levels?
*
Yes
No
Do you have low steroids or cortisol levels?
*
Yes
No
Do you have arthritis, bursitis, or any inflammatory issues?
*
Yes
No
Do you have any other "-itis"(inflammatory) conditions? If yes, state them below.
*
Yes
No
Inflammatoryconditions:
*
FEMALES ONLY
Are your menstruation's irregular? (pituitary gland)
*
Yes
No
Do you get excessive bleeding during menstruation?
*
Yes
No
Do you have or have you ever had a yeast infection? How often?
*
Yes
No
Do you have or have you ever had ovarian cysts?
*
Yes
No
Do you have or have youever had uterine fibroids?
*
Yes
No
Do you have or have you ever had endometriosis or A-typical cells?
*
Yes
No
Do you have fibromyalgia or scleroderma?
*
Yes
No
Do you get sore breasts, especially during menstruation?
*
Yes
No
Do you have a low or excessive sex drive?
*
Yes
No
Have you had a hysterectomy?
*
Yes
No
Date:
*
hysterectomy
*
Partial
Complete
Did they take any other organs out at the same time?
*
Yes
No
If so, which organ(s)?
*
Have you had a dilation and curettage procedure?
*
Yes
No
Date:
*
Have you had a miscarriage?
*
Yes
No
Have you had difficulty in conceiving children?
*
Yes
No
Have you been on Birth Control Pills?
*
Yes
No
If yes, how long?
*
Are you currently pregnant?
*
Yes
No
GASTRO INTESTINAL TRACT
Do you have:
*
gastritis
enteritis
colitis
diverticulitis
If yes, please specify which:
*
Is your tongue coated (white, yellow, green or brown), especially in the morning?
*
Yes
No
Do you have gastro paresis?
*
Yes
No
Do you have a Hiatus Hernia?
*
Yes
No
Do you have gas problems?
*
Yes
No
Do you get or have Constipation?
*
Yes
No
Do you get or have Diarrhea?
*
Yes
No
Do you or have you ever had, stomach or intestinal ulcers?
*
Yes
No
Do you have Crohn's Disease?
*
Yes
No
Do you or have you ever had any type of gastro-intestinal cancers?
*
Stomach
Colon
Rectal
Please specify:
*
Any other gastrointestinal tractissues?
*
Yes
No
If yes, please specify below
*
LIVER/GALLBLADDER/BLOOD
Do you have a problem digesting fats?
*
Yes
No
Do you have, or have you ever had, hepatitis?
*
A
B
C
No
Do fats or dairy foods cause bloating and/or pain in the stomach area?
*
Yes
No
Are your stools white or very light brown in color?
*
Yes
No
Do you get pain in the middle of your back (especially after eating)?
*
Yes
No
Do you get pain behind the right, lower rib area?
*
Yes
No
Do you have "liver" or brown spots on your skin? (not freckles)
*
Yes
No
Do you have any skin pigmentation changes?
*
Yes
No
Do you have skin problems?
*
Yes
No
If so, what type?
*
Are you or have you ever been anemic?
*
Yes
No
HEART & CIRCULATION
Do you get chest pains or angina?
*
Yes
No
Have you ever had a heart attack (Myocardial Infarction)?
*
Yes
No
Do you have, or have you ever had High Blood Pressure? (kidneys)
*
Yes
No
Do you ever feel pressure on yourchest?
*
Yes
No
Do you have heart arrhythmias?
*
Yes
No
Do you have a heart murmur or Mitral Valve Prolapsed?
*
Yes
No
Have you ever had open-heart surgery?
*
Yes
No
Do you get "prickly' pains anywhere, especially in the heart area?
*
Yes
No
If yes, where?
*
Do you have a pacemaker or stints?
*
Yes
No
If yes, please specify:
*
LUNGS
Do you get or have (or have had) had bronchitis?
*
Yes
No
Do you get or have (or have had) had asthma?
*
Yes
No
Do you have or have you ever had emphysema?
*
Yes
No
Do you have or have you ever had C.O.P.D?
*
Yes
No
Are you on inhalers or nebulizers?
*
Yes
No
How often? What type?
*
Do you know what your oxygen saturation is?
*
Yes
No
If yes, please state:
*
Do you get pain when you breathe?
*
Yes
No
Do you get pain when you take a deep breath?
*
Yes
No
Do you haveor have you ever had lung cancer?
*
Yes
No
Do you have a collapsed lung?
*
Yes
No
Have you ever had pneumonia?
*
Yes
No
Have you ever worked around toxic chemicals, in coal-mines or around asbestos?
*
Yes
No
Do you cough a lot?
*
Yes
No
Do you get any mucus when you cough?
*
Yes
No
What color is the mucus?
*
SKIN
Do you get or have skin rashes?
*
Yes
No
Do you get skin blemishes?
*
Yes
No
Do you have Eczema or Dermatitis?
*
Yes
No
Do you have Psoriasis?
*
Yes
No
Do you itch anywhere?
*
Yes
No
If yes, where?
*
Is your skin dry?
*
Yes
No
Is your skin excessively oily?
*
Yes
No
Do you get or have dandruff?
*
Yes
No
Do you have skin problems?
*
Yes
No
If so, what type?
*
LYMPHATIC SYSTEM
Do you have hair loss or are you bald or going bald?
*
Yes
No
Do you have swollen lymph nodes?
*
Yes
No
Have you ever had any lymph nodes removed?
*
Yes
No
How many? Where?
*
Have you had your tonsils out?
*
Yes
No
If yes, at what age?
*
Do you have, or have you ever had, a goiter?
*
Yes
No
Do you have a hard time remembering things?
*
Yes
No
Is your immune system weak or sluggish?
*
Yes
No
Do you ever get colds or flu-like symptoms?
*
Yes
No
Do you have fibromyalgia or scleroderma?
*
Yes
No
Do you have a sore throat or get sore throats often?
*
Yes
No
Do you have sinus problems?
*
Yes
No
If yes, when?
*
Do you have or have you had tumors?
*
Yes
No
If Yes, what type?
*
Fatty
Benign
Cancerous
Where?
*
Do you get boils, pimples, and the like?
*
Yes
No
Do you have, or have you ever had, cellulitis?
*
Yes
No
Have you ever had abscesses?
*
Yes
No
Have you ever had gout?
*
Yes
No
Have you ever had toxemia?
*
Yes
No
Do you have a low platelet count (blood)?
*
Yes
No
Do you get blurred vision?
*
Yes
No
Do you have mucus in your eyes when you wake up in the morning?
*
Yes
No
Do you snore?
*
Yes
No
Do you have sleep apnea?
*
Yes
No
KIDNEYS & BLADDER
Have you ever had a urinary tract infection (UITI's)?
*
Yes
No
Have you ever experienced "burning" upon urination?
*
Yes
No
Do you have problems holding your bladder?
*
Yes
No
Have you ever had kidney stones?
*
Yes
No
Do you have bags under your eyes (esp. in the morning)?
*
Yes
No
Is your urine flow restricted?
*
Yes
No
Do you get cramping or pain on either side of your mid-to-lower back?
*
Yes
No
Do you have or have you ever had sciatica?
*
Yes
No
Do you have or have you ever had nephritis?
*
Yes
No
Do you have or have you ever had cystitis?
*
Yes
No
Chemical Medications-Please list any chemical medications that you are presently taking:
Medication Name & Reason For Taking
*
Natural Supplements - Please list any natural supplements you are currently taking:
Supplement(s)
*
Surgeries - Please list any past surgeries you have had (e.g. tonsils removed, hysterectomies, open heart surgery, etc.)
Surgery
Date of Surgery & Surgery
*
ENVIRONMENTAL TOXINS
Have you been vaccinated?
*
Yes
No
Have you had shots for travelling to foreign countries?
*
Yes
No
Have you had Flu shots?
*
Yes
No
Do you find it difficult to take deep breaths?
*
Yes
No
Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals?
*
Yes
No
Have you had radiation or chemotherapy? If so, how many treatments?
*
Yes
No
Sleep - Please describe how much sleep you get/need on average per day
Sleep Pattern
*
Allergies - Please list anything that you are allergic to
Allergies
*
AMALGAM FILLINGS
Do you have, or have you had, any dental amalgam fillings?
*
Yes
No
If yes, how many? In the past
*
If yes, how many? Currently
*
Do you consume alcohol?
*
Yes
No
Do you consume caffeine?
*
Yes
No
Do you smoke?
*
Yes
No
GENETIC HEALTH HISTORY
Mother
*
Father
*
(Maternal) Grandfather
*
(Maternal) Grandmother
*
(Fraternal) Grandfather
*
(Fraternal) Grandmother
*
Sisters
*
Brothers
*
What is your primary health complains or concerns?
Please list and elaborate on any conditions or symptoms that this questionnaire has not covered or asked you.
*
- Thank You -
Submit
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