I. Personal Information
Name*
Birth Date
Address*
City*
State*
Zip*
Occupation
Phone*
Email*
Height
Weight
pounds
Sex
Blood Type
II. Body Systems Questionnaire
Please select every symptom that you experience.
Abdominal pain or discomfort
Absent-mindedness or forgetfulness
Acid indigestion or heartburn
Anxiety, nervousness or tension

Asthma
Bad breath or body odor
Brittle fingernails
Burning or painful urination

Cold hands and feet
Colitis or other bowel irritations
Congested air passages
Constipation or dry stools

Cravings for fat or high fat diet
Cravings for sugar
Dark circles or puffiness under eyes
Difficulty getting to sleep

Dizziness or light headedness
Dry Skin
Excess mucus production
Family history of heart disease

Fatigue in the afternoons
Fatigue or low energy levels
Food allergies
Food sits heavy on stomach after eating

Frequent backache
Frequent cough
Frequent infections
Frequent urinary tract infections

General weakness or chronic illness
Hayfever
Heart problems
High blood pressure

High cholesterol
Impotency (males only)
Infertility
Intestinal gas or bloating

Itchy nose and ears
Joint pain, arthritis or gout
Leg cramps or pains
Less than 1 bowel elimination per day

Loose stool or diarrhea
Loss of appetite or poor appetite
Loss of sexual desire
Menopause problems (females)

Menstrual problems (females)
Mental / emotional stress
Migraine headaches
Muddled thinking, confusion or mental sluggishness

Osteoporosis
Pale complexion and/or anemia
Prostate problems (males)
Restless dreams or nightmares

Scant or excessive urination
Sinus congestion
Sinus headaches
Skin problems (acne, rashes, etc.)

Stiff, aching, or painful muscles
Swollen lymph glands
Ulcers
Underweight or unable to gain weight

Urinating at night
Varicose veins
Waking up frequently at night
Water retention or edema

Weak legs, knees or ankles
Wheezing or shortness or breath
Wounds won't heal on extremities, i.e. arms, hands, legs, feet

III. Lifestyle Habits
Briefly describe your current eating habits.
How much water do you drink each day?
cups
What type of water do you drink?
What nutritional supplements are you currently taking?
What prescription medications are you currently taking?
If you could improve 3 things about your health, your body, or how you feel, what would they be?