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BASIC INFO

First Name

Last Name

Today’s Date

Email Address

Mobile Phone

Birthdate

Street Address 1

Street Address 2

City

State

Zip Code

Biological Gender

Female

Male

Marital Status

Single

Married

Divorced

Widowed

Number of Children

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INTERNAL & EXTERNAL STIMULI

What are the main reasons you are seeking our services today?

What is your frequency drinking coffee and tea?

What is your frequency with recreational drug use?

What is your frequency using tobacco?

What is your frequency drinking water?

What is your frequency drinking soda / pop?

Please list any medications you are currently taking.

Name, Reason, Duration

Please list any supplements you are currently taking.

Name, Reason, Duration

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LIFE ASSESSMENT

How do you feel about your Significant Other?

How do you feel about your Family?

How do you feel about your Diet?

How do you feel about your Sex Life?

How do you feel about Yourself?

How do you feel about your Work?

How do you feel about your Spirituality?

How do you feel about your Exercise?

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BODY CONDITIONS & ISSUES

How often do you experience issues with Excessive Appetite?

Frequently

Sometimes

Never

How often do you experience issues with Digestion?

Frequently

Sometimes

Never

How often do you experience issues with Heartburn / Reflux?

Frequently

Sometimes

Never

How often do you experience issues with Lower Back Pain?

Frequently

Sometimes

Never

How often do you experience issues with Insomnia?

Frequently

Sometimes

Never

How often do you experience issues with Laughing Without Reason?

Frequently

Sometimes

Never

How often do you experience issues with Sadness / Depression?

Frequently

Sometimes

Never

How often do you experience issues with Digesting Greasy Foods?

Frequently

Sometimes

Never

How often do you experience issues with Fatigue?

Frequently

Sometimes

Never

How often do you experience issues with Ear Ringing?

Frequently

Sometimes

Never

How often do you experience issues with Gallstones?

Frequently

Sometimes

Never

How often do you experience issues with Bitter Taste in your Mouth?

Frequently

Sometimes

Never

How often do you experience issues with Colitis / Diverticulitis?

Frequently

Sometimes

Never

How often do you experience issues with Usually Feeling Warm?

Frequently

Sometimes

Never

How often do you experience issues with Dizziness?

Frequently

Sometimes

Never

How often do you experience issues with Lack of Appetite?

Frequently

Sometimes

Never

How often do you experience issues with Vomiting?

Frequently

Sometimes

Never

How often do you experience issues with Bloating?

Frequently

Sometimes

Never

How often do you experience issues with Knee Problems / Pain?

Frequently

Sometimes

Never

How often do you experience issues with Palpitations?

Frequently

Sometimes

Never

How often do you experience issues with Chest Pains?

Frequently

Sometimes

Never

How often do you experience issues with Eye Problems?

Frequently

Sometimes

Never

How often do you experience issues with Cough / Coughing?

Frequently

Sometimes

Never

How often do you experience issues with Edema?

Frequently

Sometimes

Never

How often do you experience issues with Kidney Stones?

Frequently

Sometimes

Never

How often do you experience issues with Soft / Brittle Nails?

Frequently

Sometimes

Never

How often do you experience issues with Difficulty Making Decisions?

Frequently

Sometimes

Never

How often do you experience issues with Constipation?

Frequently

Sometimes

Never

How often do you experience issues with Usually Feeling Cold?

Frequently

Sometimes

Never

How often do you experience issues with Obsessed with Work and Personal Relationships?

Frequently

Sometimes

Never

How often do you experience issues with Loose Stool / Dirrhea?

Frequently

Sometimes

Never

How often do you experience issues with Belching / Burping?

Frequently

Sometimes

Never

How often do you experience issues with Nasal / Nose Problems?

Frequently

Sometimes

Never

How often do you experience issues with Hearing Impairment?

Frequently

Sometimes

Never

How often do you experience issues with Cold Hands / Feet?

Frequently

Sometimes

Never

How often do you experience issues with Hearing Impairment?

Frequently

Sometimes

Never

How often do you experience issues with Poor Memory?

Frequently

Sometimes

Never

How often do you experience issues with Jaundice?

Frequently

Sometimes

Never

How often do you experience issues with Shortness of Breath?

Frequently

Sometimes

Never

How often do you experience issues with Asthma?

Frequently

Sometimes

Never

How often do you experience issues with Decreased Sex Drive?

Frequently

Sometimes

Never

How often do you experience issues with Anger / Easily Angered?

Frequently

Sometimes

Never

How often do you experience issues with High Cholesterol?

Frequently

Sometimes

Never

How often do you experience issues with Depression?

Frequently

Sometimes

Never

How often do you experience issues with Anxiety?

Frequently

Sometimes

Never

How often do you experience issues with Headaches?

Frequently

Sometimes

Never

How often do you experience issues with Claustrophobia?

Frequently

Sometimes

Never

How often do you experience issues with Skin Problems?

Frequently

Sometimes

Never

How often do you experience issues with Bruising Easily?

Frequently

Sometimes

Never

How often do you experience issues with Nightmares?

Frequently

Sometimes

Never

How often do you experience issues with Vivid Dreams?

Frequently

Sometimes

Never

How often do you experience issues with Decreased Sense of Smell?

Frequently

Sometimes

Never

How often do you experience issues with Dental Problems?

Frequently

Sometimes

Never

How often do you experience issues with Hair Loss?

Frequently

Sometimes

Never

How often do you experience issues with Urinary Problems?

Frequently

Sometimes

Never

How often do you experience issues with Frequent Sickness / Easily Sick?

Frequently

Sometimes

Never

How often do you experience issues with Bloody Stool / Hemmorrhoids?

Frequently

Sometimes

Never

How often do you experience issues with Light or Clay Colored Stool?

Frequently

Sometimes

Never

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BIOLOGICAL FEMALES

Age of Menarche

First Period

Numbers of Days in Cycle

Color of Flow

Number of Days of Flow

Clots?

Yes

No

Are you Pregnant?

Yes

No

Number of Pregnancies

Number of Abortions

Have you ever been diagnosed with Fibroids?

Yes

No

Have you ever been diagnosed with Fibrocystic Breasts?

Yes

No

Have you ever been diagnosed with HPV?

Yes

No

Have you ever been diagnosed with Endometriosis?

Yes

No

Have you ever been diagnosed with Pelvic Inflammatory Disease (PID)?

Yes

No

Have you ever been diagnosed with Ovarian Cysts?

Yes

No

Is Cramping associated with your menstrual cycle?

Yes

No

Is Stabbing Pain associated with your menstrual cycle?

Yes

No

Are Headaches associated with your menstrual cycle?

Yes

No

Are Mood Changes associated with your menstrual cycle?

Yes

No

Is Nausea associated with your menstrual cycle?

Yes

No

Is Increased Appetite associated with your menstrual cycle?

Yes

No

Are Hot Flashes associated with your menstrual cycle?

Yes

No

Is Discharge associated with your menstrual cycle?

Yes

No

Date of your last Gynecologic Exam

Date of your last Mammogram

Date of your last Pap Smear

Results of your last Pap Smear

Age of Menopause

Last Period

Do you wake at night to Urinate?

Yes

No

If you wake to Urinate, how many times per night?

Is there anything else you would like to explain regarding your condition?

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BIOLOGICAL MALES

Date of your last Prostate Exam

Do you experience Dribbling Urine?

Yes

No

Do you experience Testicular Pain?

Yes

No

Do you experience Incontinence?

Yes

No

Do you experience Decreased Libido?

Yes

No

Do you experience Groin Pain?

Yes

No

Do you experience Delayed Stream?

Yes

No

Do you experience Something Other?

Yes

No

Do you wake at night to Urinate?

Yes

No

If you wake to Urinate, how many times per night?

Is there anything else you would like to explain regarding your condition?