| Name: | |
| Date of birth: | |
| What are your health concerns? | |
| Are you hungry when you wake up in the morning? | |
| What do you usually eat for breakfast? | |
| What do you usually eat for lunch? | |
| What do you usually eat for dinner? | |
| Do you snack? | |
| If yes, what do you snack on and how often? | |
| Do you eat desserts? | |
| If yes, what desserts and how often? | |
| How much water do you drink? | |
| Coffee? | |
| Tea? | |
| Juice? | |
| Pop? | |
| Milk? | |
| Alcohol? | |
| Other? | |
| What time to you go to bed at night? | |
| How long does it take you to fall asleep? | |
| Do you sleep through the night? | |
| if no, what time(s) do you wake and for how long? | |
| What time do you wake in the morning? | |
| How is your morning energy upon waking? | |
| What time of day is your energy at its best? | |
| What time of day is your energy at its worst? | |
| How often do you have a bowel movement? | |
| Is your stool well formed? | |
| What color is your stool? | |
| Does you stool float or sink? | |
| Do you get gas or bloating? | |
| Do any foods bother your stomach? | |
| How often do you urinate? | |
| Do you have any urinary urgency? | |
| Do you feel like you have urinated completely? | |
| Do you have any known or suspected allergies? | |
| At what age did you start your menstrual cycle? | |
| How many days between your cycles? | |
| How many days do you bleed with your cycle? | |
| Do you have any discomfort with your cycle? | |
| How many times have you been pregnant? | |
| How many children do you have? | |
| Have you reached menopause? | |
| Do you have any menopausal/perimenopausal symptoms? | |
| Are you teeth sensitive to hot, cold or chewing | |
| Have you ever had a root canal? | |
| Do/did you have any mercury/silver/amalgam fillings? | |
| Have you had any teeth removed? | |
| Do you have any crowns, bridges, partials or implants? | |
| Do you have any pain? | |
| If yes, where? | |
| To your knowledge, have you ever been exposed to metals or chemicals? | |
| Do you smoke | |
| If known, were you born by C-Section? | |
| Were suction or forceps used during your birth? | |
| How often do you catch a cold? | |
| How long do your colds last? | |
| Have you had any accidents(broken bones, stitches, etc)? | |
| Have you had any surgeries | |
| Please list any prescriprion drugs you are currently taking: | |
| Please list any vitamins, minerals or supplements you are currently taking: | |
| Do you have any stresses (relationships, health, time, money or others) in your life? | |
| Do you exercise? | |
| If yes, what type of exercise and how often? | |
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