Your Name:
A value is required. Please fill in Name Age
***. Invalid format.
Address:
City:
Email:
A value is required. Invalid format.
Phone Number
A value is required. Invalid format.
Height
A value is required.
Current Weight
A value is required.
Weight Last Year
Desired Weight
Weight 5 years ago
When was your last physical exam?
A value is required.
Occupation
Living Situation
Please describe any major health concerns and intentions for your consultation with me
A value is required.
Please list any other health care providers or consultants you are currently working with
Please list any health conditions diagnosed by a medical doctor
Please list all herbs, vitamins, and dietary supplements you are currently taking, including dosage and frequency
List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over the counter (OTC) or Prescription, including dosage and frequency
List all medications, herbs, foods, environmental factors, to which you have a known allergy:
Dietary Information
Describe below your typical meals. type of oil , such as olive, corn, etc. Instead of “bread” list whether white or whole grain, etc. Instead of “vegetables” list the type of vegetable, how prepared, canned, frozen, or fresh, etc.
And please write what you are ACTUALLY eating, good and bad! (not what you should be eating, as this skews the results)
Breakfast
A value is required.
Morning Snacks
Lunch
A value is required.
Afternoon Snacks
Dinner
A value is required.
Evening Snacks
How many 8oz glasses of water do you drink a day?
A value is required. Invalid format.
At what time do you eat your last full meal?
Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list as many as applicable including time of day or month
Family History
Please describe any relevant or major health related issues: (cancer, mental illness,diabetes, heart disease, etc.)
Mother:
Father:
Sister(s):
Brother(s):
Grandmother
Grandmother
Grandfather
Grandfather
List all major health problems including any operations and the YEAR (eg. appendix removed: 2004)
General Health
LIFESTYLE HABITS
Please click all those that describe you:
Do you engage in regular physical activity?
How Many Minutes?
Do you smoke tobacco?
How Much?
Do you Drink Alcohol?
How Much?
Do you drink Coffee, Tea, Ice-Tea, Coke, etc.
How Much?
How Often?
How many hours of TV do you watch a week?
Do you use artificial sweeteners?
Please use the following space to add any comments which you may feel are important to note or would be helpful
Please list approximate dates and describe the nature of any traumatic experiences youhave had in the past 7 years (divorce, surgery, end of a relationship, loss of job, change of residence, injury, death of a loved one, etc.)
Please press the SEND BUTTON below
