Please fill out the following health survey. I will review it and contact you for your free consultation.
Name:
Street address:
City:
State:
Zip:
E-mail:
Home Phone:
Mobile Phone:
How should I contact you?
Home Phone
Mobile Phone
E-mail
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Date of Birth:
Age:
Height:
Current Weight:
Weight 6 months ago:
Weight 1 year ago:
Would you like your weight to be different?
Yes
No
If so, what weight?
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Relationship status:
Choose
Married
Single
Divorced
Widow
How many children:
None
One
Two
Three
Four
more
Occupation:
How many hours do you work per week:
Do you sleep well:
Very well
well
average
poorly
very poorly
If you wake up during the night, what time?
Is it to urinate?
Yes
No
Sometimes
Do you experience constipation or diarrhea?
Constipation
Diarrhea
Both
Neither
What time do you normally wake up in the morning?
What is your blood type?
Choose
AB
AB-
A+
A-
B+
B-
O+
O-
What is your ancestry?
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FOR WOMEN:
Do you have regular periods?
Yes
No
How many days is your flow?
Choose
I don't have periods
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
How frequent:
Painful or symptomatic:
Yes
No
Sometimes
please explain:
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Do you take medication or supplements? If so, which ones?
Are there any healers, helpers or therapies with which you are involved? Please list:
How often do you excercise:
Choose
5-7 times per week
2-4 times per week
0-1 times per week
I don't exercise
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked:
Where do you get the rest from?
Serious illness / hospitalizations / injury
How is the health of your mother?
How is the health of your father?
What is your chief concern?
Other concerns:
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What foods did you eat as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What foods did you eat one year ago?
Breakfast
Lunch
Dinner
Snacks
Liquids
What's your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
