Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate
*
MM
DD
YYYY
Gender
*
Where did you grow up?
Who do you share your home with?
Occupation:
Passion/Interests:
What are your top three main concerns, in order of importance? Feel free to go into details...
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Do you exercise adequately?
How much time total per week?
What exercise do you do?
Do you sleep well?
How many hours per night?
Do you nap?
Do you like your work?
How many hours per week do you work?
Are you satisfied with your energy levels?
What would you describe as the two dominant emotions in your life at this time?
Symptom Checklist
Please check any of these symptoms or diseases you have had in the past or present:
Please list any illnesses in your family history (such as Cancer, Heart disease, High blood pressure, Low blood pressure, Diabetes, Asthma, Depression, Stroke, Allergies, Headaches, Joint disease, Alcoholism) and who experienced them. e.g. mother: hypertension and heart disease.
Do you have any allergies? If so, what are they to?
List any prescription or non-prescription pharmaceuticals you take on a regular basis with amounts and how long you have been taking them.
List any herbs, supplements or vitamins you take now or took previously on a regular basis. Include dates and amounts.
Please list major events in the last ten years of your life and the dates they occurred, this includes births, deaths, marriage, divorce, accidents, moves, job changes, miscarriages, illness and anything else you feel greatly impacted your life.
Do you have regular bowel movements?
How many bowel movements do you have a day?
How many per week?
Is it ever difficult?
How do you feel after eating?
Do you have regular bloating?
Do you wake to urinate?
How many times per night?
Would you describe your libido as
Have you experienced any of the following, past or present?
Menstrual and/or Menopausal age of onset?
Do you have regular cycles?
# of days in your cycle?
# of days flowing?
How would you describe your flow?
Please check any symptoms that accompany your cycle:
Date of your last pelvic exam or PAP? Results?
Are you currently sexually active?
What is your pregnancy history? (abortion, live birth, miscarriage, etc.)
Birth Control
Please check all that you have used in the last ten years
Breakfast- Time? Beverages? Good day/ bad day?
Snack? (Mid Morning)
Lunch- Time? Beverages? Good day/ bad day?
Snack? (Mid Afternoon)
Dinner- Time? Beverages? Good day/ bad day?
Dessert?
