Before we get started, please click the buttons below todownload, complete and send the Informed Consent Agreement. Click here to download and sign the Informed Consent Agreement Click here to email me the agreement Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * Address * Age * Gender * Height * Weight * Desired Weight * Marital Status * Single Married Divorced Widowed Other Referred By: What is your Current family/living situation? * What is it that you are interested in achieving? * What is your occupation? * Describe all symptoms, dates of onset and any other pertinent information * None Arthritis Chronic Bronchitis Cataracts Diverticulosis Glaucoma Heartburn/Gastric Reflux Hypertension Leg/Foot Ulcers Osteoporosis Migraines Urinary Tract Infections Allergies Bipolar Disorder Congestive Heart Failure Dementia/Memory Loss Eating Disorder Gout Hepstitis Hypoglycemia Liver Disease Pneumonia Thyroid Disease Anemia Blood Clot COPD/Breathing Problems Depression Emphysema Heart Attack High Cholesterol Kidney Disease Obesity Seizures Tuberculosis Anxiety Cancer Coronary Artery Disease Diabetes Fibromyalgia Heart Disease HIV Kidney Stones Liver Problems Stroke Ulcers Please describe any current or past medical condition that is not included in the list above: * Have you ever been diagnosed with any form of cancer? * Yes No Smoking Status * Current Smoker Former Smoker Non Smoker ALCOHOL USE: Do you drink alcohol, beer, or wine? * Yes No Please list any relevant family history: * Medications & Supplements * Yes No Allergies * Yes No Neurological Brain function * None Chronic or frequent headaches Numbness and tingling anywhere Dizziness Ringing or noises in the ear Tremors in hands, feet, lips, eyelids Psychological, Liver, Kidneys, Bladder Function * None Shyness or Timidity Mood Changes Loss of self-confidence Crying spells Insomnia Irritability Loss of Memory Attention Deficit Syndrome Anger and loss of self-control Anxiety Nervousness Inability to concentrate Decline of intellect Depression Drowsiness Digestive/Immune & Gut Dysfunction * None Foul Breath Chronic inflammation of gums Bleeding gums Excessive salivation Bone loss and loosening of teeth Metallic taste Oral Cavity * None Irritable bowel syndrome Loss of appetite Abdominal cramps Colitis Voracious appetite and obesity Constipation or diarrhea Nausea Excessive thirst Other problems * None Skin rashes, especially around the face/neck Optic nerve degeneration Excessive perspiration without fever Dim or double vision Low body temperature/clamminess Hypoxia (lack of oxygen) Neurological/ Mood * None Anxiety Memory Problems Headaches Other Depression Autism Schizophrenia Seizures ADD/ADHD Bipolar Disorder Alzheimer’s Migraines Short term memory * Yes No Sometimes Coordination or balance problems * Yes No Sometimes Lack of impulsivity control * Yes No Sometimes Poor organization abilities * Yes No Sometimes Problems with time management * Yes No Sometimes Mood Instability * Yes No Sometimes Difficulty understanding speech or finding words * Yes No Sometimes Brain fog, brain fatigue * Yes No Sometimes Lower effectiveness at work or school * Yes No Sometime What activity level does your job entail? * None (seated only) Moderate (light activity) High (heavy labor) Has a doctor ever told you that you should not exercise? * Yes No How many days a week are you physically active? * Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month Do you follow a specific eating style or diet? * Yes No Which of the following foods & beverages do you consume regularly? * None Alcohol Refined Sugar Soda Diet Soda Dairy (milk, cheese, yogurt) Fast food Gluten (wheat, rye, barley) Do you eat lots of greens on a daily basis? * Never Always Rarely Occasionally What percentage of your meals are home cooked? * 0 10 20 30 40 50 60 70 80 90 100 Do you avoid certain foods because of the way they make you feel, if so, what are they? * Are there foods that you crave, if so, what are they? * In the past 3 years, how many courses of antibiotics have you been on? * On average, how many fruit juices or fizzy drinks do you have a week? * How many teaspoons of sugar do you have in your tea or coffee? * What do you snack on during the day? * Around what time in the evening do you stop eating? * On average, how much water do you drink a day? * On average, how many hours of sleep do you sleep at night? * How long does it take you to fall asleep once in bed? * What time do you usually go to sleep? * Do you have issues staying asleep through the night? * Never Rarely Sometimes Often Very Often How would you rate your sleep quality? * Very Poor Poor Average Good Do you use electronic devices while in bed? * Never Rarely Sometimes Always How many times do you snooze your alarm in the mroning? * 0 1 2 3+ On a scale of 1-10, (1 lowest -10 highest) how would you rate your general level of anxiety/stress? * How stressful do you consider your job? * Not Stressful Slightly Stressful Stressful Very Stressful How would you say that you manage your stress? * Are there any other things that cause you notable stress? * How much time on average, do you spend scrolling on social media? * If there are any, please list any habits you have been wanting to cut out? * If there are any, please list any habits or lifestyle changes you have been wanting to bring in? * Please rate your readiness for change: (one being the lowest 10 being the highest). * Do you think that your family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? * Yes No Who in your family or on your health care team will be the most supportive of your lifestyle changes? * What are your health goals and aspirations and tell me why? * Thanks for submitting your information! I will get back to you as soon as possible.
