First name:

Last name:

email address:

Age:

Date of Birth (DD/MM/YYYY):

Sex: Male Female

Number of Amalgam (Silver) fillings:

Blood type (if known) (ex: AB, A, B, 0 and +, -):

Please list all serious medical conditions you have been diagnosed with by your doctor:

Please list all hereditary conditions experienced by members of your family:

Please list all medications and supplements you are currently taking:

Please list all known allergies (foods, medications, dust, pollen, dogs, etc.)

How many serious physical injuries have you experienced in the past? (ex: car accidents, broken appendages, back injuries. etc)

How many major infections have you had in your lifetime? (ex: Pneumonia, Bronchitis, Sinusitis, any other major infection that was treated with antibiotics)

On a scale from 1 to 10, 10 being the highest, how would you rate your daily personal stress level (1-10)

Do you smoke? Yes No

If Yes, how many cigarettes do you smoke a day on average?

How many cups of coffee or other caffeinated drinks do you normally consume in a day?

How many days do you exercise in an average week?

How many sugar, sweet type products do you consume a day? (candy, cake, icecream, non-caffeinated drinks, etc)

How many cups of water do you consume a day?

Please use the space below to describe any health goals and concerns you would like addressed: