Name
*
First Name
Last Name
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone
(###)
###
####
Home Phone
(###)
###
####
Preferred Method of Contact
*
Select one
Email
Cell Phone
Home Phone
Work Phone
Date of Birth
MM
DD
YYYY
Place of Birth
Age
Gender
Select one
Female
Male
Height & Weight
Desired weight
Occupation
Hours worked per week
Relationship Status
Select one
Single
Married
Divorced
Other
Any children?
Blood type (if known)
Referred by
Hobbies & Activities
Health Concerns & Goals (please list)
What do you want to accomplish from this consultation?
Do you sleep well? What time do you go to bed and wake up??
How do you feel when you wake up?
How much water do you drink each day?
Do you drink?
Please list how much of the above beverages you drink, and how often.
Do you smoke? (If yes, how much and how often?)
Are you or were you exposed to secondhand smoke? (If yes, when and how often.)
Have you been exposed to toxic substances at work or home?
Please list any prescription medications, non-prescription medications (ex. aspirin), vitamins, minerals, herbs, etc. you take (include amounts).
Do you have any allergies to medications or herbs? Please explain.
Are you currently under a practitioner’s care for specific health issue(s)? If yes, please explain:
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and date:
How often do you eat out? What percentage of your food is home cooked?
How much packaged or pre-prepared food do you eat?
What are the three worst foods you eat each week?
What are the three best foods you eat each week?
Do you crave sugar or salt?
Select one
Sugar
Salt
Sugar and salt
Does eating cause you to feel unwell, tired, gassy or bloated? Please explain. (Ex., eggs, general stomach issues, etc.)
What were your eating habits like a child? (List types of foods)
Family health history
Check all that apply and please explain in the space below.
Mother: age/if deceased, cause
Father: age/if deceased, cause
Maternal Grandmother: age/if deceased, cause
Paternal Grandmother: age/if deceased, cause
Paternal Grandmother: Age/If deceased, cause
Paternal Grandfather: age/if deceased, cause
WOMEN ONLY
Select your age at your first period
8
9
10
11
12
13
14
15
16
Are your periods regular? How frequent?
Number of days of flow?
Do you experience PMS? Is it mild or severe?
Are you peri-menopausal or menopausal? What age did this occur. Please explain symptoms below.
How many children have you delivered? Were they born vaginally or by c-section?
Were there any complications with any of the births? Please explain.
Did you receive antibiotics during labor?
Have you ever had a miscarriage or an abortion? How many?
MEN ONLY
Select the approximate age of onset of puberty
9
10
11
12
13
14
15
Do you feel your libido is adequate?
Select one
Yes
No
Do you wake at night to urinate? How many times per night?
Do you have any difficulty and/or pain with urination?
Do you enjoy daily activities? Do you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc.?
Do you notice feeling more agitated/irritable than previously?
Do you feel less assertive in daily life than previously?
Would you like to discuss any men’s health issues specifically?
