Name
*
First Name
Last Name
Phone
(###)
###
####
Date of birth
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Family Doctor
Emergency Contact (Name & Phone Number)
*
Occupation(s)
Do you have insurance?
If yes, please indicate provider & insurance number :
Chief Complaint/Description
Has it improved or worsen?
Current Medications/Supplements (Please include dose, length, reason)
Allergies/Sensitivities (Food, Medications, Herbs, Topicals)
Major Surgeries, Accidents, or Illnesses
How do you rate your energy level from 1-10 (1 being the lowest)
*
How do you rate your average stress level? 1-10 (1 being the lowest)
*
General Health
Check all that apply
Diet
Are you or have you recently been on any of the following diet plans?
Check all that apply
How often do you eat?
If other, how often?
When do you eat most meals?
Do you experience cravings?
If yes, what do you crave?
Physical Health
Check all that currently apply
Health Conditions
Check all that apply
Are you currently experiencing pain?
Please describe the pain
Check all that applies :
What relives the pain?
LMP
Pregnancies
Check all that apply
Mothers Health / Pregnancy (gestation, complications, delivery)
Men's Health History
Do you have high cholesterol?
Have you recently had any prostate conditions?
Do you have or had you had any urinary infections or STD's?
How would you define your sexual energy?
Additional Information
