CONFIDENTIAL HEALTH HISTORY

Name
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Full Address
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Email Address
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How often do you check your email?
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Home
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Telephone-Work
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Cell
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Occupation
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Hours Per Week
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Age
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Date of Birth
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Place of Birth
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Height
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What is your ancestry?
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What is your blood type?
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Current Weight
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Weight six months ago
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One year ago:
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Would you like your weight to be different?
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If so what?
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Please list major health concerns:
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When was the last time you felt really vibrant and well?
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Other current major life concerns?
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If you would wave a magic wand and change two things what would they be?
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Any serious illness, hospitalization, injuries, and surgeries, either now or in your past?
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Do you sleep well?
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How many hours?
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Wake up at night?
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Why?
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Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
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How is the Health of your mother? (If deceased relay illness)
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How is the health of your father? (If deceased relay illness)
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This Section Is For Women Only

Are your periods regular?
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How Frequent?
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Please Explain:
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How many days is your flow?
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Painful or Symptomatic?
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Birth Control History:
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Vaginal infections, reproductive concerns?
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End of Women's Section

Do you struggle with Constipation, Diarrhea, Gas, Distension, Belching, or Bloating? Which? :
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Please Explain in Detail:
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Please list ALL supplements or medications you take (prescription or over-the-counter) and frequency?
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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?
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Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?
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What is the general status of your dental/health care?
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Any troubling dental work or history of dental/oral infections? Dentures? Root canals?
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How many silver/mercury fillings do you have? Other major dental work/issues beyond basic cleanings?
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On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?
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To what do you attribute this energy level?
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Any healers, helpers, pets or therapies with which you are involved? Please list:
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What are your primary hobbies?
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What role do sports and exercise play in your life?
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What do you do to relax? How often?
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What was your general health and well-being as a child?
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What foods did you eat as a child?
Breakfast
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Lunch
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Dinner
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Snacks
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Liquids
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What's your food like these days?
Breakfast
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Lunch
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Dinner
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Snacks
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Liquids
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Do you have any food allergies or sensitivities?
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What percentage of your food is home cooked?
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What percentage is not?
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Where do you get the rest from?
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If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly
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Do you crave sugar, carbs, alcohol, coffee, cigarettes, other foods, or have any addictions?
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Anything else you would like to share?
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Please also complete the symptom questionnaire.

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