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Email *
Daytime phone *
Mobile phone
Current Age *
Occupation *
Marital / Family Status *
Please list all herbs, vitamins and supplements you are currently using. If none, please write none. *
Please list all medications you are currently using. If none, please write none. *
Please list all medical conditions you are currently being treated for. If none, please write none. *
Please list any allergies that you are aware of, diagnosed or suspected? If none, please write none. *
Please list any major accidents, broken bones, concussions, whiplash, sport injuries, etc.
Please list any surgeries (with approximate age)
Please list any major dental work done (braces, teeth removal, root canals, fillings, etc)
Please list any treatments or other therapies you are currently using *
Please list any treatments or other therapies you have used in the past and for what. If none, please write none. *
Were you born pre-maturely?
Was your birth uncomplicated?
How was your health as a child?
Where there any significant traumas/episodes, with approximate age (divorce, loss of a family member, abuse, other traumatic events, etc)
How many times per day?
How many hours per day do you look at a screen? (computers, phone, television, etc)
What type of physical activity do you engage in and for how long? (walking, sports, weight/strength training, running, other physical activities, etc)
If no, what is your ideal weight?
Please explain any dietary restrictions (religious, vegetarian, vegan, dairy free, gluten free, low histamine, etc) or specialized diets (GAPS, FODMAPS, keto, bariatric, etc)
What areas of your life are affecting your stress levels? *
Any addictions? (Food, gaming, gambling, phone, sex, drugs, social media, etc)
Any recent traumas/episodes?
Is there anything else you feel would be important to share? *
What areas, problems or goals would like help with now? List in order of importance. *
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By typing your first and last name in the box below, you agree that you have read, understood and agree to the above statements. (If under that age of 18 years old, the name typed will be that of a parent or guardian.) *