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 [radio excess-iron “yes” “no] 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
