Well Life Intake Questionnaire 1

Well Life Intake Questionnaire 1

September 21, 2023

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*

First Participant's Date of Birth*

First Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

First Participant's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Second Participant's Name

First Name*

Middle Name

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Third Participant's Name

First Name*

Middle Name

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Fourth Participant's Name

First Name*

Middle Name

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Fifth Participant's Name

First Name*

Middle Name

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Sixth Participant's Name

First Name*

Middle Name

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Seventh Participant's Name

First Name*

Middle Name

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Eighth Participant's Name

First Name*

Middle Name

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Ninth Participant's Name

First Name*

Middle Name

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Tenth Participant's Name

First Name*

Middle Name

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Parent or Guardian's Email Address

Email*

Confirm Email*

Check to receive information, news, and discounts by e-mail.

Participant's Address

Address Line 1:*

Street address, P.O. box, company name, c/o

Address Line 2:

Apartment, suite, unit, building, floor, etc.

Country:*

City:*

State/Province:*

Zip/Postal:*

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Information

Relationship status

Occupation

Hours per week

Referred by

Family History

Paternal Family Illnesses

Paternal Family Member

Illness

Paternal Family Member

Illness

Paternal Family Member

Illness

Maternal Family Illnesses

Maternal Family Member

Illness

Maternal Family Member

Illness

Maternal Family Member

Illness

Personal Health History

Medical Diagnosis

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Diagnosis

Current

Past

Date of Onset

Past Hospitalizations/Surgeries

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Hospitalization/Surgery

Date

Reason

Have you ever taken antibiotics? *

Yes

Have you ever taken birth control? *

Yes

Have you ever been on hormone replacement therapy?*

Yes

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Supplement

Dose

Frequency

Start Date

Reason

Medications

List all medications you're currently taking

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

Medication

Dose

Frequency

Start Date

Reason

List your current health concerns in order of importance

Health Concerns

Do you experience digestive difficulties?

(i.e. bloating constipation, gas, constipation)

How often do you have a bowel movement?

Do you strain to have a bowel movement? *

Yes

Are your bowels loose?*

Yes

Do you take laxatives?*

Yes

List any food or environmental allergies you experience

Food/Environmental Allergies

Reaction

Do you avoid these foods? *

Yes

Diet

How much water do you drink daily?

Do you consume coffee? *

Yes

Do you consume tea? *

Yes

Do you consume alcohol?*

Yes

List any other drinks you consume

How many times a week do you eat meat?

How many vegetables do you eat per day?

How many fruits do you eat per day?

What are your favorite foods?

What foods do you avoid?

Do you experience any symptoms after meals?

Describe your relationship with food Please be very specific

Lifestyle

How many hours do you sleep a night?

Do you have trouble falling asleep? Staying asleep? You wake frequently during the night?

Do you wake feeling rested? *

Yes

How often do you exercise?

What types of exercise do you do?

What do you do to have fun?

How do you express your creativity?

Do you have any pets? *

Yes

What level of stress are you currently experiencing?

List your main stressors

Please provide any other information that may be relevant but hasn't been covered in regard to emotions

How many hours per day do you use a computer?

How many hours per day do you use a cell phone?

How many hours per day do you use watch TV?

Chemicals

Where did you grow up? City or country?

City

Country

What type of environment do you/ have you worked in?

How many cigarettes do you smoke per day?

For how many years? If you quit, how long ago?

Do you or have you used recreational drugs? *

Yes

Have you had any dental work done? Do you have fillings (metal), root canals, crowns, etc?

Have you ever had shots/vaccinations? List all that apply (including flu shots)

Is there anything that will get in the way of following a treatment plan in order to achieve results?

What is your level of commitment to improving your health?

1 = Lowest, 10 = Highest

Parent or Guardian's Signature*

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