PART 1: CLIENT INFORMATION
Name
*
First Name
Middle Name
Last Name
Suffix
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Method of Contact
*
Phone
Email
DOB (Date of Birth)
*
Height
*
Weight
*
Primary MD Physician
*
Physician Address & Phone
*
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Next
PART 2: LIFESTYLE QUESTIONNAIRE
Routines
Rate your daily energy level:
1
2
3
4
5
6
7
8
9
10
Lethargic
Supercharged
1 is Lethargic, 10 is Supercharged
Are you currently on a specific diet?
No
Yes
Do you get at least 30 minutes of activity &/or exercise per day?
No
Yes
Rate your daily activity level:
1
2
3
4
5
6
7
8
9
10
Sedentary
Insanely High
1 is Sedentary, 10 is Insanely High
Do you ever crave junk, fatty, or sugary foods?
No
Yes
Do you avoid meat sources?
No
Yes
Do you avoid dairy sources?
No
Yes
Do you avoid fat sources?
No
Yes
Do you avoid high-carb sources?
No
Yes
Do you avoid grain sources?
No
Yes
Do you avoid gluten sources?
No
Yes
How many times per week do you have a bowel movement?
1-3
4-6
7+
Do you have a difficult time losing weight?
No
Yes
Do you have a difficult time gaining weight?
No
Yes
Do you regularly fast (in periods of time or from specific food groups)?
No
Yes
Do you smoke or use tobacco?
No
Yes
Are you exposed to second-hand smoke?
No
Yes
Do you use antiperspirant with aluminum?
No
Yes
Do you regularly use hair dye or bleach?
No
Yes
Are you regularly exposed to chemicals (in either home or work life)?
No
Yes
Supplements & Vitamins
List all supplements & vitamins you're currently taking:
Diet
How often do you consume alcohol?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume alternative sweeteners?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume candy / junk food?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume carbonated / soft drinks?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume chicken?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume coffee?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume dairy products?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume energy drinks / products?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume fast food or processed foods (e.g. frozen dinners)?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume fried foods?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume margarine?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume pasta?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume pork?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume raw / fresh fruits?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume raw / fresh vegetables?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume red meat?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume refined / processed sugars?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume salty foods?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume seafood?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume soy (organic)?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume tea (herbal / non-caffeinated)?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume tea (regular / caffeinated)?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume water (bottled / purified / spring / well)?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
How often do you consume water (tap)?
0
1
2
3
4
5
6
7
8
9
10
Never
Excessively
0 is Never, 10 is Excessively
Rate how much of your diet is comprised of organic /or natural foods?
*
0
1
2
3
4
5
6
7
8
9
10
None of it
All of it
0 is None of it, 10 is All of it
Food Allergies
List any food known food allergies (leave blank if you have none or are unsure):
3-Day Meal Recall
List your Breakfast, Lunch, Dinner, Snacks, & Drinks (inc. portions) from 3 days ago:
*
List your Breakfast, Lunch, Dinner, Snacks, & Drinks (inc. portions) from 2 days ago:
*
List your Breakfast, Lunch, Dinner, Snacks, & Drinks (inc. portions) from yesterday:
*
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Next
PART 3: MEDICAL QUESTIONNAIRE
Medications
How often do you take acetaminophen (Tylenol)?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take anti-inflammatory medicine?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take antacids?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take antibiotics /or anti-fungal medicine?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take anti-depressant medicine?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take anti-diabetic /or insulin medicine?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take Aspirin (or other NSAIDs)?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take birth control (e.g. oral contraceptives)?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you undergo chemotherapy (or other radiation therapy)?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take cortisone /or anti-histamines?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take heart medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take /or receive hormone treatments?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take hypertension medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take laxative medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take lithium?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take prostate medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you use recreational drugs?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take sex- / libido- enhancing medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take sleep / relaxant medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
How often do you take thyroid medication?
0
1
2
3
4
5
6
7
8
9
10
Never
Constantly
0 is Never, 10 is Constantly
Prescriptions
List all prescriptions you're currently taking:
Personal Medical History
Have you ever been pregnant?
No
Yes
Have you ever taken birth control in excess of 12 months?
No
Yes
Have you ever had mononucleosis?
Unsure
No
Yes
Have you ever had tuberculosis?
Unsure
No
Yes
Have you ever had hepatitis or Jaundice?
Unsure
No
Yes
Has your LDL cholesterol ever exceeded 200?
Unsure
No
Yes
Has your triglyceride level ever exceeded 150?
Unsure
No
Yes
Have you ever experienced pain down your left arm?
Unsure
No
Yes
Have you ever experienced a "crushing" chest pain?
Unsure
No
Yes
Have you had your spleen removed?
Unsure
No
Yes
Have you ever experienced cramps while walking?
Unsure
No
Yes
Do your feet often tingle or get cold easily?
Unsure
No
Yes
Have your legs ever felt "heavy"?
Unsure
No
Yes
Have your calf veins ever appeared swollen?
Unsure
No
Yes
Have you ever had ankle or foot swelling?
Unsure
No
Yes
Have you ever felt fatigued after minor exertion?
Unsure
No
Yes
Have you ever had a dry, persistent cough (not allergy or virus related)?
Unsure
No
Yes
Have you ever experienced heartburn?
Unsure
No
Yes
Have you ever had persistent / recurrent fungal infections?
Unsure
No
Yes
Do you have a small / thin frame?
Unsure
No
Yes
Do you have a very fair / light complexion?
Unsure
No
Yes
Do perfumes or other chemicals bother you?
Unsure
No
Yes
Do humid days or moldy areas provoke symptoms?
Unsure
No
Yes
Symptoms
List all symptoms (inc. allergies) you are experiencing &/or are concerned about:
Family Medical History
Has anyone in your family been diagnosed with a blood clot?
Unsure
No
Yes
Has anyone in your family been diagnosed with erratic behavior?
Unsure
No
Yes
Has anyone in your family been diagnosed with Alzheimer's (or another mental disease)?
Unsure
No
Yes
Has anyone in your family been diagnosed with tremors?
Unsure
No
Yes
Has anyone in your family been diagnosed with hypoglycemia?
Unsure
No
Yes
Has anyone in your family been diagnosed with diabetes?
Unsure
No
Yes
Has anyone in your family been diagnosed with osteoporosis?
Unsure
No
Yes
Has anyone in your family been diagnosed with hypertension?
Unsure
No
Yes
Has anyone in your family been diagnosed with a heart disease?
Unsure
No
Yes
Has anyone in your family been diagnosed with cancer?
Unsure
No
Yes
Has anyone in your family been diagnosed with ADD or ADHD?
Unsure
No
Yes
Has anyone in your family been diagnosed with Asperger's or autism?
Unsure
No
Yes
List any other conditions, not listed, that your family has been diagnosed with:
Personal Notes
Add any additional notes that you feel should be added to your file:
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PART 4: TERMS & DISCLAIMERS
By checking the box below, I agree that I've completed this form to the best and truest of my knowledge.
I agree with the statement above
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