Name*
Email*
Phone*
Weight*
Unit* kglb
Height*
Unit* cminft
Age*
Date of Birth*
Sex*
Please list your 5 major health concerns in order of importance: Please list your 5 major health and fitness goals in order of importance: Do you wish to gain, lose, or maintain your current body weight? [cf7mls_step cf7mls_step-1 "NEXT" ""]
Feeling that bowels do not empty completely
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Lower abdominal pain relief by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard dry or small stool
Coated tongue or "fuzzy" debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables
Undigested food found in stools
Stomach pain, burning or aching 1-4 hours after eating
Use antacids frequently
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk, carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
Roughage and fiber cause constipation
Indigestion and fullness lasts 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Nausea and/or vomiting
Excessive passage of gas
Stool: undigested, foul smelling, mucous-like, greasy, or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight
Greasy or high-fat foods cause distress
Lower bowel gas and or bloating several hours after eating
Bitter metallic taste in mouth especially in the morning
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay-colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded if meals are missed
Eating relieves fatigue
Feel shaky, jittery, tremors
Agitated, easily upset, nervous
Poor memory, forgetful
Blurred vision
Fatigue after meals
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
Cannot fall asleep
Perspire easily
Under high amounts of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity
Tired, sluggish
Feel cold - hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight gain even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression, lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face or genitals, or excessive falling hair
Dryness of skin and/or scalp
Mental sluggishness
Heart palpations
Inward trembling
Increased pulse even at rest
Nervousness and emotional
Insomnia
Night sweats
Difficulty gaining weight
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
Increased sex drive
Tolerance to sugars reduced
"Splitting" type headaches
Urination difficulty or dribbling
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night
Decrease in libido
Decrease in spontaneous morning erections
Decrease in fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
Are you menopausal?
Alternating menstrual cycle lengths
Extended menstrual cycle, greater than 32 days
Shortened menses, less than every 24 days
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne breakouts
Facial hair growth
Hair loss/thinning
How many years have you been menopausal?
Do you ever have uterine bleeding since menopause?
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Acne
Increased vaginal, pain, dryness, or itching
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How many alcohol beverages do you consume per week?
How many caffeinated beverages do you consume per day?
How many times do you eat out per week?
How many times a week do you eat raw nuts or seeds?
How many times a week do you eat fish?
How many times a week do you workout?
List the three worst foods you eat during the average week?
List the three healthiest foods you eat during the average week?
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Do you smoke? If yes, how many times a day?
Rate your stress levels on a scale of 1-10 during the average week:
Please list any medical condition(s) that you have been diagnosed with in the past:
Please list all medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
Has a doctor recommended that you take specific vitamins, minerals, or other supplements for your health? If yes, please list which ones:
Please list any allergies you have:
Are there any ingredients that may be found in a natural supplement that you are allergic to? If yes, please list which ones:
Are you aware of any supplements that may interfere with a medication that you are taking? If yes, please list which ones:
Do you have any concerns from taking natural supplements? If yes, please list your concerns:
Please list any other information that you believe is relevant that may affect your health or safety when taking a natural supplement:
If you require clarification for any of the questions above, please contact our office prior to submitting your answers.
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