Client Name     Date  Email     Phone Extension What is your main health concern? Are you in pain, if so, please describe in detail. If you've had any blood work done recently what were the results: What, if any medications do/did you take for these problems and what were they for? How long have you had this illness? Have you ever had an operation? Yes No If you answered yes, when and why? How would you describe your personality: (independent, insecure, depressed, confident, reserved, happy, dependent, bold, moody etc.) Please expand on your answer. Is your home or work life stressful? Do you have any physical problems that you believe are not related to the current problem? (eyes, ears, nose, throat, bowels, kidneys) List: Have you ever received any vaccines? Yes  No If yes, which vaccines and when / dates if available or approximate dates: Do you have any fillings, crowns, bridges or impants? If so, how many and what are they made of? Do you have or have you had allergies? Yes  No Please list any allergies: What type of allergic reactions do you have: When was the last time you had this/these reaction/s: What did you do to treat the reaction: What illnesses have you had in the past year: What treatments were used: How would you describe your appetite: What types of food do you prefer, salty, spicy, sweet, dairy, meat, etc.? Do the foods you prefer agree with you? What is your basic diet? How would you describe your energy level: Are you sensitive to light, sound, touch, etc. What were your childhood diseases: Do you get infections easily: Do you recover quickly: Are you prone to swollen lymph glands: Are you prone to ear infections? Are you exposed to any of the following: Pesticides, chemicals, Oils and petroleum's, Aerosols, Paint or paint products? This includes beauty products of all kinds including hair dye. List all that apply: Do you consider yourself under or overweight: Does skin appear healthy: Are kidney/urinary and bowel movements regular? Do you have back, spine, joint or muscle pains of any kind? List: Has your hair greyed prematurely? Any discomfort with reproductive organs? List: Have you visited any foreign countries? Yes  No If yes, when; and list what, if any, required vaccines: Does your daily routine require you be in public spaces? Ex: Parks, Public Buildings, Hotels Or anyplace where the general public comes and goes. List: What medications or supplements do you take daily? Please list any health problems that run in your family. Any other comments? Thank you for taking the time to fill out this consultation form! Please remember I am NOT a medical doctor [MD]. Before you click the Submit button, please follow this security procedure typing the number in the box to the left, into the box to the right. Security #: <- type this # into this box ->