Please enable JavaScript in your browser to complete this form.Today's Date *Name *Age *Sex *MaleFemaleAddress *City *State *Zip Code *How were you referred *What are your main health concerns or conditions *Please list any medications or food supplements you are currently taking *Please list any recent medical tests results you have, such as blood tests *Please list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis. *DietWhat are examples of typical meals for you?Breakfast *Breakfast Beverages *Lunch *Lunch Beverages *Supper *Supper Beverages *Evening Snacks *Evening Snacks Beverages *ActivityHow often and what kind of exercise do you do? *About how many hours of sleep do you get per day? *SYMPTOMSSYMPTOMSJoint_PainJoint_StiffnessArthritis,_OsteoArthritis,_RheumatoidMuscle_PainMuscle_WeaknessMuscle_CrampsBursitisFracturesOsteoporosisGoutSweet_CravingsSugar_ReactionsIrritable_before_mealsCant_Skip_MealsHypoglycemiaCrave_StarchesFat_CravingsOther_Food_CravingsFood_AllergiesExcessive_hungerNo_hungerDiabetesRapid_Heart_RateSkipped_Heart_BeatsHeart_PalpitationsHeart_AttackPoor_CirculationDizzinessLow_Blood_PressureHigh_Blood_PressureAnginaArteriosclerosisHigh_CholesterolHigh_TriglyceridesCoughBronchitisAsthmaPost-nasal_DripSinus_CongestionAllergiesEmphysemaFatigueHypothyroidismLow_Body_TemperatureCold_in_Winter/Dry_SkinTend_to_Gain_WeightHyperthyroidismAcneEczemaFungal_Infections/CandidaPsoriasisHivesHair_LossSlow_Wound_HealingCataractsGlaucomaMenieres_DiseaseTooth_DecayExcessive_Tooth_PlaqueGum_DiseaseInfections/VirusesMultiple_SclerosisParkinsons_DiseaseSclerodermaAngerAnxietyBipolar_DisorderBrain_FogConfusionDepressionIrritabilityMind_RacesMood_SwingsObsessive/CompulsivePanic_AttacksPoor_MemorySchizophreniaTrouble_SleepingAutismAttention_DeficitHyperkinesisDyslexiaSeizuresLearning_DisabilityMental_RetardationDelayed_DevelopmentBladder_InfectionsKidney_InfectionsTrouble_UrinatingFrequent_UrinationPainful_UrinationKidney_StonesWater_RetentionKidney_StonesWater_RetentionSinus_HeadachesTension_HeadachesMigraine_HeadachesNeuritisEye_diseasesConstipationDiarrheaIntestinal_GasBloatingHeartburnUlcerStomach_PainColitisGall_StonesFissuresHemorrhoidsCirrhosisDiverticulitisTend_to_Gain_WeightTend_to_Lose_WeightAnemiaEasy_BruisingDrug_AddictionAlcoholismSmokingTumorCancerMENS SYMPTOMSMENS SYMPTOMSProstate_ProblemsImpotenceInfertilityWOMENS SYMPTOMSWOMENS SYMPTOMSPremenstrual_SyndromeWater_RetentionCrampsNo_MenstruationHeavy_periodsLight/Irregular_PeriodsOvarian_CystsFibroid_TumorsAbnormal_Pap_SmearMenopauseFibrocystic_BreastsBreast_TumorsYeast_InfectionsHot_FlashesWhich symptoms concern you the most. *Other Symptoms. *How do you want your results delivered *Email Audio MP3Phone ConsultationPlease provide email address and phone numberSubmit
