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Valerie.Bledsoe
Don't let your health hold you back!
1 (620) 491-1810
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Provide your basic health information so that I may have a baseline prior to your consult.
Client Information
Name
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Address
Street Address
City
State
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Armed Forces Pacific
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Day Phone
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Cell Phone
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Relief From What Top 3 Symptoms (see below)
What Are Your Life Goals?
Lifestyle Information
How Much Sweaty Activity Weekly?
What Types of Activities?
How Many Ounces of Water do you Drink Daily?
What Type of Water do you Drink?
Reverse Osmosis
Tap
Spring
Distilled
Well
Which Meals Do You Eat Daily?
Breakfast
Lunch
Supper
How Many Eliminations per Day?
How Many Digestive Enzymes Daily?
How Many Breathing Exercises Daily?
How Much of the Following do You Consume?
(example: 1D = once daily, 3M = 3 times monthly)
Soda Pop
Coffee
Smoking
Alcohol
Fast Food
Milk
White Flour
Sugar Usage
Raw Fruit
Meat
Raw Veggies
Whole Grains
What Types of Foods do You Crave?
Salty
Chocolate
Sweets
Breads
Other
What are Your Favorite Foods?
How Much Daily Energy Do You Have?
What Surgeries Have You Had and When?
(type None if applicable)
How Many Hours of TV do You Watch?
(example: 1D = 1 hour daily, 3M = 3 hours monthly)
How Many Hours of Spiritual Enrichment Each Week?
(bible, prayer, church, etc.)
How Many Hours a Week do You Spend with Family/Friends?
How Many Hours of Sleep do You Get Each Night?
How Many Hours of Sleep do You Need?
What Prescription Medication do You Take?
(type None if applicable)
Would You Like to Receive Our Natural Health Newsletter?
Yes
No
Who Referred You for Your Appointment Today?
Health Information
Symptoms of Concern
(check all that apply)
Acne
ADD/ADHD
Adrenal Glands
Allergies
Alzheimer's Disease
Anema
Anger
Anxiety
Appetite
Arteriosclerosis
Arthritis
Asthma
Back Pain
Bad Breath
Bed Wetting
Bell's Palsy
Bites
Bladder
Blood Pressure (hight)
Blood Pressure (low)
Boils
Bones
Breathing
Bronchitis
Bruises
Burns
Cancer
Candida
Canker Sores
Carpal Tunnel
Cataracts
Chest Congestion
Chest Pain
Cholesterol
Circulation
Cold (common)
Cold (temperature)
Colic
Colon
Constipation
Cough
Cravings
Dandruff
Depression
Diabetes
Diarrhea
Digestion
Dizzy Spells
Ear Infection
Ear Ringing
Edema
Emphysema
Epilepsy
Eyesight
Fatigue
Fever
Flu
Gallstones
Gangrene
Gas
Gout
Gums
Hair Issues
Headache
Heart Issues
Heartburn
Hemorrhoids
Herpes
Hiatal Hernia
Hives
Hormones
Hyperactive
Hypertension
Hyperthyroidism
Hypoglycemia
Impotence
Incontinence
Indigestion
Insomnia
Joint Pain
Kidney Issues
Kidney Stones
Laryngitis
Leprosy
Leukemia
Liver
Lung Issues
Lupus
Lymph Glands
Menopause
Menstrual Cramps
Migraines
Mononucleosis
Mucous
Nails
Nausea
Nervousness
Nose Bleeds
Parasites
Parkinson's Disease
Perspiration
PMS
Pneumonia
Polyps
Pregnancy
Prostate
Psoriasis
Rash
Reproductive
Respiratory
Rheumantism
Ring Worm
Seizures
Shingles
Sinus
Skin Issues
Snoring
Sore Throat
Stomach
Stress
Stroke
Sty
Teething
Tennis Elbow
Tonsillitis
Tumors
Ulcers
Urinary Infections
Varicose Veins
Vertigo
Weight (overweight)
Weight (underweight)
Yeast Infections
What Other Symptoms are You Concerned About?
I am over weight
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I feel as though I am in good health
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Name
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Health Info
Evaluator
Get in Touch
Testimonials