Please
provide the following contact information:
First
Name:
Last
Name:
Street
Address:
City:
State:
Zip
Code:
County:
Home
Phone:
FAX:
E-Mail:
Date
of Birth:
Who
referred You:
Number
of organs removed, including teeth:
How
manyprescription drugs do you use:
How
many cigarettes/cigars do you smoke per
day:
Number
of steroid type drugs used in the last
year:
Number
of street drugs used in the past:
How
many different allergies:
What
is bothering you emotionally or mentally:
(depression, anger, anxiety)
On
a scale of 1-10, how responsible are
you for your health:
1
2
3
4
5
6
7
8
9
10
Select One
How
much fat is in your diet (2-low, 3-medium,
4-high):
2-Low
3-Medium
4-High
Select One
Your
negativity level (from 1-10):
1
2
3
4
5
6
7
8
9
10
Select One
What
is your personal stress level (from 1-10):
1
2
3
4
5
6
7
8
9
10
Select One
Do
you take vitamins daily:
YES
NO
Select One
How
many sugar type products do you have a
day:
How
many exercise sessions of 20 mins or more
a week:
On
average, number of alcoholic drinks per
day:
Number
of cups of coffee or tea with caffeine
a day:
Number
of extreme toxic exposures per year (radiation,
insecticides, chemicals):
What
major injuries have you had in the past
(accidents, falls, surgery):
Number
of major infections:
How
many glasses of water do you drink a day:
How
many pounds overweight, if any:
How
do you feel on a scale of 1-10 (lowest
to highest):
1
2
3
4
5
6
7
8
9
10
Select One
What it Does