* First and Last Name

* Email

* Phone

* Street Address

* City | State | Zip Code

Occupation

* Birth Date

Referred By

* What are Your Health Challenges? (in order of importance)

First Symptoms: (please enter approximate dates below)

Trauma

Emotional

Physical

Mental

* What Medications are You Currently Taking? (include birth control, over-the-counter medicine, therapies)

* What Do You Take These Medications For?

* What Nutritional Supplements are You Taking?

* What Do You Take These Supplements For?

Diet, Nutrition and General Health Practices:

* Breakfast

* Lunch

* Dinner

* Snacks

* How Much Water Do You Drink Daily?

* What Other Beverages Do You Consume Daily?

Do You Crave the Following Foods? (please use the drop down menus below to indicate Yes or No)

Salty SaltyYesNo

Chocolate ChocolateYesNo

Starches StarchesYesNo

Alcohol AlcoholYesNo

Sweets SweetsYesNo

Fats FatsYesNo

Caffeinated Beverages Caffeinated BeveragesYesNo

List Any Other Type of Food Cravings You Have:

* How Often Do You Exercise? How Many Days Per Week?

* What Kind of Exercise(s) Do You Do?

* How Many Hours of Sleep Do You Get Each Night on Average?

* Do You Have Difficulty Falling Asleep at Night?

If Yes, What Time? What Causes You to Wake Up?

* How Would You Describe Your Energy Level?

* How Would You Rate Your Stress Level?

* How Would You Rate Your Support System? (family, friends, church, etc.)

* How Often Do You Have Bowel Movements Per Day?

* Do You Experience Cramping? Pains? Loose Stools?

* How Would You Describe Your Digestion?

* Do You Experience Gas, Bloating, Stomach Problems on a Regular Basis?

* Do You Smoke?

Additional Comments