Health Questionnaire

Health Questionnaire
Full Name *

First Name Last Name
Sex *

Male Female
Weight *
Birth Date *

Month Day Year
E-mail *
Phone Number *

Area Code Phone Number
What's your main health concern(s)? *
How does this affect your life? How long have you had this and how often? *
What have you tried in the past that hasn't worked? *
Do you have any injuries that we need to know about? *
Symptoms that you experience

Insomnia Low Energy Acid Reflux Bloating or Gas Irregular Bowel Movements - Less than 1 a day Headaches, Migraines Chronic Pain Weakened Immune System Weight Gain Acne Food Allegies Skin Rashes, Itching
Check if you eat, drink, or use

Alcohol Candy Luncheon Meats Cigarettes Soft Drinks Gatorade/Sugary Drinks Fast Food Fried Foods Other Recreational Drugs
Please list all medications you are currently taking
Please list all supplements you are currently taking
On a scale of 1-10, what is your commitment on getting well?
What is your ideal outcome? *
Should be Empty: