Health Questionnaire

Health Questionnaire
Full Name*

First NameLast Name
Sex*

MaleFemale
Weight*
Birth Date*

MonthDayYear
E-mail*
Phone Number*

Area CodePhone 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

InsomniaLow EnergyAcid RefluxBloating or GasIrregular Bowel Movements - Less than 1 a dayHeadaches, MigrainesChronic PainWeakened Immune SystemWeight GainAcneFood AllegiesSkin Rashes, ItchingOther
Check if you eat, drink, or use

AlcoholCandyLuncheon MeatsCigarettesSoft DrinksGatorade/Sugary DrinksFast FoodFried FoodsOther Recreational DrugsOther
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: