Health Form





Your Name (required)

Date of Birth

Height

Weight

Your Email (required)

Children and Ages

Please describe you most pressing issue

Fatigue

Cold extremities (hands/feet)

Do you have weight control issue? Please describe

Are you tired in the morning, energetic at night? yesno

Do you have problems with water retention, especially noticeable in the face and around the eyes? yesno

Do you experience bloating or indigestion after eating? yesno

Do you have problems with short term memory? yesno

Do you notice white spots on fingernails? yesno

Easily constipated or chronic constipation? yesno

Do you have PMS symptoms? yesno

Are you peri-menopausal? yesno

Are you in the menopausal transition? yesno

Are you taking any hormone replacement therapy for menopause? If so write down the prescription name of the hormone(s) or the name of the nutraceutical or supplement:

Are you susceptible to emotional or mood swings? yesno

Difficulty getting deep breaths yesno

Brittle nails or slow growing nails yesno

Do you have or have had ovarian cysts yesno

Hair loss from scalp, legs or arms yesno

Unexplained nervousness yesno

Unexplained heart palpitations yesno

Bruise easily yesno

Burning sensation after eating yesno

Do you have problems with chronic infections yesno

Do you have high cholesterol. Do you know your cholesterol levels?

Have you been diagnosed with artheroplaque yesno

Do you have a history of cystic breast tissue (lumpy breast tissue)? yesno

Do you have any of the following symptoms:

Psoriasis yesno

Eczema yesno

Hepatitis yesno

Autoimmune disease: Which one: please explain

Acne yesno

Diverticulosis yesno

Crohn’s disease yesno

Ulcerative Colitis yesno

Low Stomach Acid or burning sensation after eating yesno

Do you suffer gas or bloating after meals? yesno

Do you have problems with diarrhea/constipation or both yesno

Do you notice mucous in your bowel movement? yesno

How many courses of antibiotics have you used in your life? What was the cause of the infection?

How many times have you used probiotics, like acidophilus?

Do you have celiac disease? If so, when was it diagnosed?

Have you been diagnosed with Irritable Bowel Syndrome? yesno

Do you crave sugar or complex carbohydrates like bread, pasta, etc. Describe
Do you read nutrition labels? yesno

Do you recognize the various descriptions of sugar? yesno

Do you suffer chronic dry skin or seasonal dry skin? yesno

Do you experience unusual thirst? yesno

Do experience blood sugar swings? yesno

Do you feel fatigued or lethargic? yesno

Do you experience episodes of muscle tremors or feeling weak? yesno

Are you fatigued after eating and worse after eating something sweet like dessert? yesno

Do experience agitation or temper outbursts? yesno

Are you easily frustrated yesno

Do you experience blurred vision? yesno

Is concentration or memory loss a problem for you? yesno

Do you have low blood pressure? yesno

Do you have chronic sinus problems? yesno

Do you find yourself clearing your throat regularly and particularly after you have eaten? yesno

How much fruit juice do you drink per day, in 8 ounce measure?

Do you have recurrent urinary tract infections? yesno

If you are a man, do you have scant or difficulties voiding yesno

Have you experienced diminished or loss of libido? For both men and women yesno

List the pharmaceuticals you are now taking

List the nutraceuticals (nutritional supplements) you are now taking. Please include Company name with the nutraceutical.

Do you experience light headedness when you go from sitting to standing or bending to standing yesno

Have you traveled abroad lately or regularly? For example, overseas, tropical, rain forest etc. Please list where and when.

If you have traveled abroad, did you notice any difference in digestion, abdominal discomfort, rectal itching, fatigue, etc. shortly after returning?

Do you experience hot flashes? yesno

Do you have night sweats? yesno

Do you have mild or severe PMS symptoms? Please explain.

Are you currently or have you used the birth control pill? For how long?

Do you carry extra weight in your stomache area? yesno

Do you carry extra weight in your hips and thigh area? [radio hips=weight “yes” “no”]

Do you consume margarine/ vegetable oils (excluding olive oil) and/or deep-fried foods on a daily basis? yesno

If you do consume any of the aforementioned fats, please describe which ones and how much you consume daily.

Have you had gall bladder surgery? When?

Do you consider yourself any of the following: vegan/ovo-vegetarian, vegetarian, no red meat, no animal protein of any kind? Please elaborate

If you are a strict vegetarian or vegan, and if you are a woman, do you experience menstrual irregularity or heavy menses? yesno

Do you take over the counter or prescription antacids? For how long?

Are you prone to migraines? Please explain frequency and duration

Do you experience frequent headaches? Please describe pressure points, frequency and duration.

Do you drink fountain or soda pop? How many per day? What flavour?

Do you experience joint pain or stiffness? yesno

Have you been diagnosed with osteoporosis? yesno

Please explain any serious injury you have suffered. When, what, how and what course of health action was taken.

Have you been diagnosed with any of the following: low iron or anemia yesno

Excessive iron levels

Are you presently on any thyroid replacement? If so, please describe name and levels yesno

Have you been tested for hypo-thyroidism using the sTSH test, T4 or T3 tests? yesno

If you have been tested, do you know the results? If so please record



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