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Health Information Form

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Provide your basic health information so that I may have a baseline prior to your consult.

Client Information
Name(Required)
First Last
Address
Street Address City State ZIP Code
Day Phone
Night Phone
Cell Phone(Required)
Email(Required)
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
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Health Information Page

Health Information Form

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Client Information

Lifestyle Information

How Much of the Following do You Consume?

Health Information