When was the last time you felt vibrant and well?
If you could wave a magic wand and change 2 things about your life right now, what exactly would they be?
Any serious illness, hospitalization, injuries, and surgeries, either now or in your past?
How is the health of your mother? If deceased, relay illnesses.
How is the health of your father? If deceased, relay illnesses.
Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
Do you struggle with Constipation, Diarrhea, Gas, Distension, Belching, or Bloating? Which?
Please list all supplements or medications you take (prescription or over-the-counter) and frequency.
Have you ever taken antibiotics more than a short course or two as a child? If so, when/how often? For what? And for how long?
Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?
What is the general status of your dental health/care?
Any troubling dental work or history of dental/oral infections? Dentures? Root canals?
How many silver/mercury fillings do you have?
Other major dental work/issues beyond basic cleanings?
On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?
Any healers, helpers, pets or therapies with which you are involved?
What role do sports and exercise play in your life?
What was your general health and well-being as a child?
Do you have any known food allergies or sensitivities?
If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly.
Do you crave sugar, carbs, alcohol, coffee, cigarettes, other foods, or have any addictions?
What two single changes do you most know you need to make in order to get healthier and reach your specific goals?
What specifically stands in the way of your making the healthier choices that you know would serve you the best?
Imagine what it will be like when you reach your specific health goals. What will this allow to happen in your life? Please give two specific benefits you are particularly excited about.
Many of our client's health situations are complex and have already been investigated by several other practitioners. Sometimes the most important ah-ha in uncovering why you are struggling is an unexpected or unconventional concept. Intuitively, what do you feel is the most important pearl of information we need to understand about how or why your health is in the state that it is right now?
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two weeks. If multiple choices are given, please specify what applies in the comment column.
Excessive mucus formation
Gagging or frequent need to clear throat
Sore throat, hoarseness, or loss of voice
Swollen or discolored tongue, gums, or lips
Chronic tooth or gum pain or jaw pain. Which?
Hives or other allergic breakout
Rash or persistently dry skin
Flushing or hot flashes
Frequently feel cold
Part of body frequently feeling numb. Which?
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Shortness of breath
Nausea or vomiting
Passing gas, flatulence
Intestinal or Stomach pain. Which?
Other pain in GI tract? Where?
Pain or aches in joints
Stiffness or limitation of movement
Pain or aches in muscles
Tremor or restless leg
Feeling of weakness or tiredness
Craving certain foods
Confusion, poor comprehension
Poor concentration or focus
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Other mood challenges?
Frequent or urgent urination
Inability to urinate or low urine flow
Low libido or other sexual dysfunction
Genital itch or discharge
Women: Breast fibroids
Women: Painful or tender breasts
Women: Uterine fibroids