Name: (Required)
Email Address: (Required)
Date of Birth (dd/mm/yyyy): (Required)
Phone: (Required)
Height: (Required)
Weight: (Required)
Sex: (Required) Male Female
Please List Your Personal Health Goals:
Please list the Diseases you've been diagnosed with:
Please list the Medications you are currently taking and for what: conditions:
Please list the Supplements you are currently taking and for what: conditions:
Do you have a Family History of Cancer (list type):
Do you have a history of Heart Disease? Yes No
Do you have a history of High Blood Pressure? Yes No
Do you have a history of High Cholesterol? Yes No
Do you have a family history of Strokes? Yes No
Do you have a family history of Diabetes? Yes No
Do you have a family history of Obesity? Yes No
Do you have a family history of Multiple Sclerosis? Yes No
Do you have a family history of Parkinson's? Yes No
Do you have a family history of Early Death? Yes No
Please feel free to elaborate on any of the above Family Histories?
Do you have a family history of any Other Diseases?
How many ounces of Water do you drink daily and what kind?
How much and what kind of Milk do you drink?
How much Soda do you drink, is it diet or regular?
How much Alcohol do you drink, what type?
How much Coffee do you drink, what type?
How much Tea do you drink, what type?
How many Energy Drinks do you drink?
How much Fruit Juice do you drink and what type, (organic/conventional)?
How much Vegetable Juice do you drink and what type, (organic/conventional)
How many Protein (Meal Replacement) Drinks do you drink?
How much fish do you eat (farm or wild)?
How much Beef do you eat?
How much Chicken do you eat?
How much Turkey do you eat?
How much Pork do you eat?
How much Ham do you eat?
Are there Other types of Meat that you eat?
How many servings per week and what kind?
Fruit servings per day?
Vegetable servings per day?
How do you prepare your vegetables?
Raw servings per day?
Cooked servings per day?
Steamed servings per day?
Juiced servings per day?
Tofu servings per day?
Miso servings per day?
Tempeh servings per day?
Nato servings per day?
Other types servings per day?
Bread slices servings per day, and what type?
Pasta servings per day?
Rice servings per day?
Corn servings per day?
Other types of Corn servings per day?
Bean servings per day?
What type and brand of cooking oil do you use?
Do you use Butter or Margarine?
Do you eat Peanut Butter, Organic or Conventional?
What kind of nuts do you eat; salted, unsalted, raw, roasted, or organic?
Do you take any Fish Oil Supplements, and the brand?
How many Avocados do you eat, and the type?
How much Flaxseed Oil do you take per day, and type?
What type of Fat Free Products do you eat?
What type of Sugar Free Products do you eat?
Do you use Sea Salt, or Iodized Salt, ant the brand?
How many Boxed or Canned Foods do you consume, and what type?
How often do you eat Fast Foods, and what type?
How ofter do you eat in Restaurants, and what type?
How often do you eat Junk Food, and type?
Have you ever had a Colon Cleanse, how ofter and what type:
Have you ever had a Liver Cleanse, how ofter and what type:
Have you ever had a Kidney Cleanse, how ofter and what type:
Have you ever had a Parasite Cleanse, how ofter and what type:
Have you ever had a Candida Cleanse, how ofter and what type:
Have you ever had a Metal Cleanse, how ofter and what type:
Have you ever tested your Urine and if so what was the pH?
How often do you Exercise per week and what type?
How often do you Sunbathe per week?
What type of Sunscreen do you use?
How often do you chew Gum and what brand?
Do you use Anti-Persirant or Deordorant and what type?
What brand of Soap do you use?
What brand of Shampoo do you use?
What brand of Laundry Soap do you use?
What brand of Skin Lotion do you use, organic or conventional?
What brand of Shaving Cream do you use, organic or conventional?
How many Bowel Movements do you have a day, 0-1, 2-3, 3-4?
How many Cigarettes do you smoke a day, and brand?
What time do you go to sleep at night?
How many hours of Sleep do you get per night?
Do you use a Microwave Oven?
Do you use a Shower Filter?
Do you use a Water Filtration System?
Do you use a Air Purifier?
Do you use Pesticides?
Do you use Air Fresheners?
Do you use Teflon Pans?
Do you use Aluminum Pans?
Do you use Aluminum Foil?
Do you use Saran Wrap?
Do you re-use Plastic Containers?
Do you re-use Plastic Water Bottles?
What is Your Stress Level?
What is Your Overall Level of Health?
Do you feel Depressed?
Are you in a Loving/Caring Relationship?
Do you enjoy your Job?
Check which of these symptoms are troublesome and persist over time. Two or more symptoms are an indication of the need to test both Estradiol and Progesterone.
Check which of these symptoms are troublesome and persist over time. Two or more symptoms are an indication that Testosterone and DHEAS testing is recommended.
Check which of these symptoms are troublesome and persist over time. Two or more symptoms are an indication that testing Cortisol for adrenal imbalance is recommended.
Additional Information:
