Please create and enter a unique 8-12 character long ID code. This is used instead of a name to ensure that your medical information is anonymous and protected. Make sure to write it down so you can relay it to me later.
[Just like any password, it can be letters and/or numbers, like "cycle982" for example. Be sure to make it unique, so avoid generic phrases like '12345678' or 'Volkswagen'.]
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What is your date of birth?
Please enter as Month/Day/Year, for example "03/15/1975"
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What are your top 3 health concerns, in order of importance?
Click all of the conditions that apply to you:
[Mark all that apply, or SKIP if you don't have any on this list]
What are your stress relief and mental wellbeing practices?
[This can be anything, from meditation, to yoga, to church, to connecting with family, to walking in nature. Skip this question if you're not sure if you have any.]
Do you regularly have any of the following digestive symptoms?
Please list any foods you are allergic to or believe you are sensitive to:
[SKIP if none]
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What did you last eat for breakfast?
[If you don't eat breakfast, write "I don't eat breakfast"]
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What did you last eat for lunch?
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What did you last eat for dinner?
List 5 of your favorite snacks
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How many ounces of water do you drink per day?
[Not counting coffee, tea, juice, soda, etc]
How much soda do you drink per day?
[This does not include sparkling water, just soda]
Have you ever taken Cipro, Levaquin, or Doxycycline?
[or any antibiotic which is called a 'quinolone']
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Please list all the medications you take, including doses
[Do your best to fill this out completely but note if the list in not complete. Write "NONE" if you do not take any medications.]
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Please list all of the supplements you regularly take [at least 1-2 times per week]
[PLEASE INCLUDE manufacturer name and product name. Do your best to fill this out completely but note if the list in not complete. Write "NONE" if you do not take any supplements.]
Have you suffered any major emotional traumas in the last 2 years?
Please list any abnormal lab findings you have had in the last year
[If you can't find them right now, that's not a problem. Try to have them handy during your session if possible. SKIP if you have not had any abnormal labs.]
