Health Form

Health Form

Submit Health Form for personalized contact
Full Name *
Date of Birth *
Height *
Weight *
Email address *
Children and Ages
Please describe what you consider to be your most pressing issues *
Fatigue
Cold extremities, hands and feet
Do you feel you have weight control issue? Please describe:
Tired in the morning, energetic at night	Yes No
Do you have problems with water retention, especially noticeable in the face and around the eyes
Do you experience bloating or indigestion after eating
Do you have problems with short term memory?	Yes No
Do you notice white spots on fingernails	Yes No
Easily constipated or chronic constipation
Do you have PMS symptoms?	Yes No
Are you peri-menopausal?	Yes No
Are you in the menopausal transition?	Yes No
Are you taking any hormone replacement therapy for menopause? If so write down the prescription name of the hormone(s) or the name of the nutraceutical or supplement:
Are you susceptible to emotional or mood swings?
Difficulty getting deep breaths	Yes No
Brittle nails or slow growing nails	Yes No
Do you have or have had ovarian cysts
Hair loss from scalp, legs or arms	Yes No
Unexplained nervousness
Unexplained heart palpitations
Muscle cramping and more pronounced at night
Bruise easily	Yes No
Do you have unpredictable and inconsistent menstrual cycle,
Burning sensation after eating	Yes No
Do you have problems with chronic infections
Do you have high cholesterol. Do you know your cholesterol levels?
Have you been diagnosed with artheroplaque	Yes No
Are you still fatigued, even after long periods of sleep	Yes No
Do you have a history of cystic breast tissue (lumpy breast tissue)?	Yes No
Do you use fluoride toothpaste?	Yes No
Do you have any of the following symptoms: Psoriasis	True False
Eczema	Yes No
Hepatitis	Yes No
Autoimmune disease: Which one: please explain
Acne	Yes No
Diverticulosis	Yes No
Crohn's disease	Yes No
Ulcerative Colitis	Yes No
Low Stomach Acid or burning sensation after eating	Yes No
Colon cancer	Yes No
Do you suffer gas or bloating after meals?	Yes No
Do you have problems with diarrhea/constipation or both	Yes No
Do you notice mucous in your bowel movement?	Yes No
How many courses of antibiotics have you used in your life? What was the cause of the infection?
How many times have you used probiotics, like acidophilus?
Do you have celiac disease? If so, when was it diagnosed?
Have you been diagnosed with Irritable Bowel Syndrome?	Yes No
Do you crave sugar or complex carbohydrates like bread, pasta, etc. Describe
Do you read nutrition labels?	Yes No
Do you recognize the various descriptions of sugar?	Yes No
Do you suffer chronic dry skin or seasonal dry skin?
Do you have problems with frequent urination? How often during do you void?
Do you experience unusual thirst?	Yes No
Do experience blood sugar swings?
Do you feel fatigued or lethargic?
Do you experience episodes of muscle tremors or feeling weak?	Yes No
Are you fatigued after eating and worse after eating something sweet like dessert?	Yes No
Do experience mood swings, agitation or temper outbursts?
Are you easily frustrated	Yes No
Do you experience blurred vision?	Yes No
Is concentration or memory loss a problem for you?
Do you have low blood pressure?
Do you feel compelled to eating sweets and/or complex carbohydrates (starches)
Do you have chronic sinus problems?	Yes No
Do you find yourself clearing your throat regularly and particularly after you have eaten?
Have you been diagnosed with attention deficit
Do you drink a large amount of pasteurized fruit juice?	Yes No
How much fruit juice do you drink per day, in 8 ounce measure?
Do you have recurrent urinary tract infections?	Yes No
Do you have exaggerated pre or post menopausal symptoms? Please explain
If you are a man, do you have scant or difficulties voiding
Have you experienced diminished or loss of libido? For both men and women
List the pharmaceuticals you are now taking
List the nutraceuticals (nutritional supplements) you are now taking. Please include Company name with the nutraceutical.
Do you experience light headedness when you go from sitting to standing or bending to standing
Do you have dark circles under your eyes, that can not be explained by ethnic predisposition?
Have you travelled abroad lately or regularly? For example, overseas, tropical, rain forest etc. Please list where and when.
If you have travelled abroad, did you notice any difference in digestion, abdominal discomfort, rectal itching, fatigue, etc. shortly after returning?
Do you experience hot flashes?	Yes No
Do you have night sweats?
Do you have mild or severe PMS symptoms? Please explain.
Are you currently or have you used the birth control pill? For how long?
Do you carry extra weight in your stomache area?	Yes No
Do you carry extra weight in your hips, stomach and thigh area?	Yes No
Do you consume margarine/ vegetable oils (excluding olive oil) and/or deep-fried foods on a daily basis?	Yes No
If you do consume any of the aforementioned fats, please describe which ones and how much you consume daily.
What colour do you describe your bowel movement?
Do you have any body parts missing...? gall bladder, etc. Please elaborate
Do you consider yourself any of the following: vegan/ovo-vegetarian, vegetarian, no red meat, no animal protein of any kind? Please elaborate
If you are a strict vegetarian or vegan, and if you are a woman, do you experience menstrual irregularity or heavy menses?
Do you take over the counter or prescription antacids? For how long?
Are you prone to migraines? Please explain frequency and duration
Do you experience frequent headaches? Please describe pressure points, frequency and duration.
Do you drink fountain or soda pop? How many per day? What flavour?
Do you experience joint pain or stiffness?	Yes No
Have you been diagnosed with osteoporosis?	Yes No
Please explain any serious injury you have suffered. When, what, how and what course of health action was taken.
Here is where you are welcome to add any other details from your health history that you wish
Here is where you will list yout 5 day basal body temperature
Here is where you will key in your Food Diary: It is important to record for 5 days. Remember to include any notable symptoms, for example gas, bloating, fatigue, how often you clear your throat, itching, sinus pressure. Your Food Diary includes everything you eat and drink during the day. Remember not to change anything during this time. It is for my Assessment purposes Only. I'm here to help not judge.
Have you been diagnosed with any of the following: low iron or anemia	Yes No
Excessive iron levels	Yes No
Are you presently on any thyroid replacement? If so, please describe name and levels	Yes No
Have you been tested for hypo-thyroidism using the sTSH test, T4 or T3 tests?	Yes No
If you have been tested, do you know the results? If so please record
Familial Health History: Please describe any significant health issues pertaining to your Father
Familial Health History: Please describe any significant health issues pertaining to your Mother
Familial Health History: Please describe any significant health issues pertaining to any of your Brothers or Sisters