PreVisit Information

Confidential Health History/Intake Form

Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. If multiple choices are given, please specify what applies in the comment column.

Leave the score blank if you Never have the symptom.
Use a 1 if you Occasionally have it and the effect is Mild
Use a 2 if you Occasionally have it and the effect is Severe
Use a 3 if you Frequently or Consistently have it and the effect is Mild
Use a 4 if you Frequently or Consistently have it and the effect is Severe

Name*

Age*

YEARS

MONTHS

Height

CMS

Weight

KGS

Place of birth

Weight 6 months ago

KGS

Weight 1 year ago

KGS

Would You like your weight to be Different

yes

If so what?

KGS

Have you tested positive for Covid-19 before?

yes

If so when did you test positive?

Have you been vaccinated for Covid-19?

yes

If so, please specify the type of Vaccine

Your Occupation

Hours of work per week

Please list your main health concerns

When was the last time you felt really vibrant and well?

Other current major life concerns?

If you could wave a magic wand and change 2 things about your life right now, what exactly would they be?

Any serious illness, hospitalization, injuries, and surgeries, either now or in your past?

How is the health of your mother? If deceased, relay illnesses.

How is the health of your father? If deceased, relay illnesses.

What is your ancestry?

What blood type are you?

Do you sleep well?

yes

How many hours?

Do you wake up at night?

yes

Why?

Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?

This section for women only

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Are your periods regular?

yes

How many days is your flow?

How frequent?

Painful or symptomatic?

Painful

Please explain

Birth control history

Vaginal infections, reproductive concerns?

Do you struggle with Constipation, Diarrhea, Gas, Distension, Belching, or Bloating? Which?

Explain in detail

Please list ALL supplements or medications you take (prescription or over-the-counter) and frequency?

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?

Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?

What is the general status of your dental health/care?

Any troubling dental work or history of dental/oral infections? Dentures? Root canals?

How many silver/mercury fillings do you have?

Other major dental work/issues beyond basic cleanings?

On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?

To what do you attribute this energy level?

Any healers, helpers, pets or therapies with which you are involved? Please list:

What are your primary hobbies?

What role do sports and exercise play in your life?

What do you do to relax? How often?

What was your general health and well-being as a child?

Do you have any known food allergies or sensitivities?

What percentage of your food is home-cooked?
What percentage is not?

If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly.

Do you crave sugar, carbs, alcohol, coffee, cigarettes, other foods, or have any addictions?

Anything else you would like to share?

Let’s Get Started on Your Wellness Journey

Confidential Health History/Intake Form

This section for women only

Please Proceed to the Symptom Questionnaire