Is this application for you or a family member?
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Have you had a hair tissue mineral analysis?
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Name of person requesting treatment
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First Name
Last Name
Email Address
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Patient's Age
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Gender
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Phone
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(###)
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International (If applicable)
Birthdate
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Status
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Important for determining stress factors.
Live with
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Pets
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Furthest Education
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Work Status
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Have you served in the military?
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Where and when did you serve?
How would you rate your experience with alternative therapies?
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Detoxification protocols, mineral rebalancing, PEMF therapy, etc.
Have you ever been treated with homeopathic therpies?
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Have you ever been treated with chiropractic therapy?
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Main health concerns
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Please list as many as you can in order of importance*
Please list your current medications:
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Please type NONE if you do not currently take any medications.
Please list your past medications:
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You took these medications for a long period of time but no longer do.
Describe any serious medical treatments you have received:
Describe any serious physical injuries:
What do you hope to achieve with alternative therapies?
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Personal Health Rating
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On a scale of 1-10, (1 = poor, 10= optimal) how would you rate your health?
How would you describe your personal health?
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How would you describe your vitality, stamina, and energy?
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Are you a warm or cold person?
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Do you prefer warm or cold drinks?
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When did your symptoms begin? What do you think caused them?
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Have you had an experience (traumatic or otherwise) that did or still does affect you deeply?
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What childhood illnesses have you had?
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Any other childhood illnesses?
Which of these tests have you undergone?
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Any other tests we should know about?
Which immunizations have you received?
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Please list your hospitalizations:
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Type of illness/operation, date, and location
Please select all that apply to your current state of health:
If you had any of these issues in the past and have recovered, please describe:
Which of these do you consume or use?
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Please describe what happens when you have an allergic attack or reaction:
Mother
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Mother's age
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Mother's cause of death
Father
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Father's age
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Father's cause of death
Siblings
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Sibling ages and causes of death if applicable:
Grandfather (Mother's side)
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Grandfather's age (Mother's side)
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Grandfather's cause of death (Mother's side)
Grandmother (Mother's side)
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Grandmother's age (Mother's side)
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Grandmother's cause of death (Mother's side)
Grandfather (Father's side)
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Grandfather's age (Father's side)
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Grandfather's cause of death (Father's side)
Grandmother (Father's side)
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Grandmother's age (Father's side)
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Grandmother's cause of death (Father's side)
Has any blood relative had any of the following?
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Neck stiffness
Neck pain and swelling
Radiating neck pain
Whiplash
Neck injuries
Middle back stiffness, dull pain
Herniated disc(s)
Arthritis (middle back)
Middle back injuries
Radiating pain (middle back)
Lower back stiffness, dull pain
Lower back radiating pain
Herniated discs (lower back)
Lower back arthritis
Lower back injuries
Limbs (joint pain, swelling, stiffness, tingling, numbness)
Where?
Limbs (muscle cramps)
Burning of soles of feet
Unusual redness of the palms or hands
Cardiovascular System
Endocrine System
Blood, Lymph, and Immune Systems
Respiratory System
Nervous System
Digestive System
Bowel movements
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How frequently do you eat?
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What does your diet consist of?
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What do you snack on?
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What food(s), condiment(s), or any other substances (i.e. tobacco, alcohol, coffee) do you crave?
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Please list any foods you severely dislike or are repelled by:
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Skin and Hair
Hair
Head
Eyes
Ears
Nose
Mouth
Throat
Mental and emotional
Do you have particular sensations? If so, what and where?
Urogenital system
Male problems
Female problems
Date of last period:
Average flow:
Every how many days?
How long does it usually last?
Describe your premenstrual symptoms:
Number of pregnancies:
Number of births:
Number of nursed children:
Trouble with lactation?
Number of miscarriages and when:
Number of abortions and when:
Complaints during pregnancy:
How old were you when you started having menstrual periods?
Do you have nipple discharge?
What form of contraception do you use?
Sleep problems and irregular sleep patterns
Are you sleepy during the day?
When?
Do you usually dream?
Do you remember your dreams?
Do you have any recurring dreams?
Insomnia
Do you wake up unrefreshed?
Do you feel sleep deprived?
Nightmares or bad dreams?
Are you too hot or cold during sleep?
Do you get nightsweats?
Are you presently on any of these treatments?
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How would you improve your health?
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Weight, skin, hair, teeth, stomach, sleep, depression, etc.
Please indicate any PAST health problems and what worked to fix them:
These are health problems that you struggled with but no longer do.
Are you having any problems with the therapy or therapies you are doing?
Have you noticed any changes in your general health since you started the therapy?
Improvements or lack of improvement in treating your health problems, sleep, vitality, mental and emotional state, etc.
Is there anything else you would like to add?
How did you hear about our services?
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If you chose personal referral or other, please type the name here:
