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  DATE:
 
 
NAME: EMAIL:
       
ADDRESS: CITY:
 
 
STATE: ZIP: PHONE:
           
FAX:        

RERRERED BY: 		       
 
 
BASIC INFORMATION
 
 
HEIGHT: WEIGHT: AGE: SEX:
   
 
MARITAL STATUS: OCCUPATION:
   
  DO YOU KNOW THE FOLLOWING LAB VALUES? (IF SO PLEASE INDICATE):
   
 
BLOOD PRESSURE: CHOLESTEROL:
       
HEART RATE: PULSE:
       
  ANY OTHER KNOWN LAB VALUES:
   
 
 
     
 
     
 
     
 
ARE YOU NOW UNDER A DOCTOR’S CARE?
   
 
IF YES,  REASON:
 
 
   
  PLEASE INDICATE HEALTH CONDITION AND ANY PRESCIRPTION MEDICATIONS TAKEN FOR THE CONDITION:
   
 
DIAGNOSIS MEDICATION(S)
   
   
   
   
   
  APPROXIMATELY HOW MUCH MONEY ARE YOU SPENDING PER MONTH ON PRESCRIPTION MEDICATION? 
   
  $
   
  PLEASE LIST ANY VITAMINS & SUPPLEMENTS YOU CURRENTLY TAKE:
   
 
SUPPLEMENT WHAT YOU TAKE IT FOR
   
   
   
   
  DO YOU TAKE ANY NON-PRESCRIPTION DRUGS?
   
 
 
 

ON A SCALE OF 1 TO 10 PLEASE RATE YOUR OVERALL HEALTH.

CHOOSE ONE NUMBER:
   
 
POOR GOOD EXCELLENT
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
 

WHAT HEALTH GOALS YOU WOULD LIKE TO ACCOMPLISH ?

ANY CURRENT SYMPTOMS YOU WOULD LIKE TO RESOLVE
   
 
GOAL #1
 
 
   
GOAL #2
 
 
   
GOAL #3
 
 
   
GOAL #4
 
 
   
   
  LIFESTYLE
   
 
DO YOU DRINK? HOW MUCH?    
           
DO YOU SMOKE? HOW MUCH?    
   
 
ANY OTHER HABITS?
   
ANY DRUG ALLERGIES?
   
ANY OTHER ALLERGIES?
   
   
  ANY FAMILY HISTORY OF HEALTH CONDITIONS?
   
 
   
  PLEASE RATE YOUR CURRENT EXERCISE HABITS.
   
 
POOR GOOD EXCELLENT
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
  WHAT TYPE OF EXERCISE DO YOU DO AND HOW LONG DO YOU DO IT?  HOW OFTEN?
   
 
   
  WHAT SPORTS DO YOU PLAY & HOW OFTEN?
   
 
   
  PLEASE RATE YOUR OVERALL STRESS LEVEL
   
 
LOW   HIGH
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
  DIET
   
  HOW WOULD YOU RATE YOUR OVERALL DIETARY HABITS?
   
 
POOR GOOD EXCELLENT
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
   
  DIET CONTINUED
   
  HOW OFTEN DO YOU EAT FAST FOOD?  TIMES PER WEEK
   
  HOW MUCH DO YOU CONSUME OF THE FOLLOWING?
   
 
LIQUID GLASSES/CUPS PER DAY (ASSUME 8OZ)
   
COFFEE
   
TEA
   
WATER
   
SODA (REGULAR)
   
SODA (DIET)
   
MILK
   
OTHER
   
  HOW WOULD YOU RATE YOUR DAIRY CONSUMPTION?
   
 
LOW AVERAGE HIGH
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
  HOW WOULD YOU RATE YOUR FOOD PORTION SIZES?
   
 
SMALL MEDIUM LARGE
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
 
DO YOU EAT:     BREAKFAST?  WHAT TIME?
       
LUNCH? WHAT TIME? DINNER? WHAT TIME?
   
  WHAT TIME DO YOU GO TO BED?
   
  DESCRIBE THE TYPE OF MEALS YOU EAT AND WHAT YOU EAT IN BETWEEN MEALS:
   
 
   
 
   
   
  SLEEP HABITS
   
  I GET HOURS OF SLEEP PER NIGHT.
   
  ON AVERAGE, MY OVERALL QUALITY OF SLEEP IS
   
 
POOR OK EXCELLENT
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
  MY BIGGEST PROBLEM WITH SLEEPING  IS
   
   
  MENTAL/SPIRITUAL
   
  ON A REGULAR BASIS, I DO ONE OF THE  FOLLOWING:
   
 
PRAY HOW OFTEN?
       
MEDITATE HOW OFTEN?
       
MASSAGE HOW OFTEN?
       
AROMATHERAPY HOW OFTEN?
       
YOGA HOW OFTEN?
       
OTHER HOW OFTEN?
   
  I DO NONE OF THE ABOVE BUT WOULD LIKE TO 
   
  I DO NONE OF THE ABOVE AND DO NOT WANT TO
   
   
  GENERAL
   
  MY OVERALL SATISFACTION WITH MY EMOTIONAL LIFE IS:
   
 
UNSATISFIED SATISFIED VERY SATISFIED
 
1        2            3            4            5            6            7            8            9            10
Enter Your Rating Here
   
  MY REASON WHY I’M NOT SATISFIED IF MY ABOVE SCORE IS LESS THAN 6:
   
 
   
  MY OVERALL SATISFACTION WITH MY s/PROFESSIONAL LIFE IS:
   
 
UNSATISFIED SATISFIED VERY SATISFIED
     
Enter Your Rating Here
   
  MY REASON WHY I’M NOT SATISFIED IF MY ABOVE SCORE IS LESS THAN 6:
   
 
   
  I WOULD LIKE TO BE CONTACTED BY THE METHOD BELOW TO OBTAIN MY RESULTS :
   
 
PHONE FAX PERSONAL VISIT (IF LOCAL)
           
EMAIL:     OTHER: 
   
  GOOD DATE/TIME TO CALL