LIFE STYLE SURVEY
PRIVATE CONSULTATION
(back to home page)
                                                  

Please answer all relevant questions.
You understand that our counseling cannot and should not replace the advice of a medical doctor and that any medical condition must be treated by a licensed physician.

1. Personal Information (Confidential)

First Name*:
Last Name*:
Date of Birth*:
(mm/dd/yyyy)
Gender*
Street*
City*
State*
Zip Code*
Telephone Number*:
Your E-Mail Address*:
Weight*:
Lbs.
Height*:
Ft.
Blood Type:
Marital status
 
Number of children
Kindly referred by:
Please give us this person's full name
List all surgeries and approximate dates: (Root canals, dental works included)
 
Explain your type of work
 



2. Diet and Nutrition

a) How often do you eat the following?

Red Meat
Flour, Cereals (White or Whole)
Sweets and sugars
Sodas
Coffee. Teas, Cokes (diet or not)
Salt or Salted Foods
Dairy Foods
Alcohol (including wine)
Poultry
Nutrasweet (sweetners)
Pork
Vegetables
Fish Fast food
Fried Foods & Cooked fats Fruit

b) More about your eating habits

Describe a typical Breakfast
Describe a typical lunch
Describe a typical dinner
What kind of water do you drink and HOW MUCH of it a day (cups)?
List all nutritional supplements you are taking
List all medications you are taking
3. General Health Practices

1. How much sleep do you get each night on the average?

2. Do you exercise? How much?

3. Do you feel that you are under stress? If so, briefly explain.

4. How often does your bowel eliminates?

4. Please list your current health concern




5. Health Symptoms
  Lack of energy Sore or painful joints
  Illness more than twice a year Difficulty in maintaining ideal weight
  Body odor and or bad breath Low endurance, stamina
  Difficulty in digesting certain foods Lack of balance diet
  Eat meat more than 3 times week Slow recovery from illness
  Monthly female concerns Less than 2 bowel movements per day
  Recent or Frequent use of antibiotics Lack of appetite
  Regular consumption of Alcohol Low sex drive
  Frequent mood swings Brittle or Easily broken fingernails
  Food allergies Dry damaged or dull hair
  Bags under eyes High fat diet
  Smoking Unsettled, apprehensive, pressured
  Poor concentration and or poor memory Low fiber diet (Not enough fruits)
  Poor resistance to disease Muscle cramps or spasms
  Belching or gas after meals Exposure to air pollution daily
  Stressful lifestyle Cokes, Sodas, Caffeine consumption daily
  Skin complexion problems Feeling out of control
  Cravings for sweets and or processed foods Food Chemical sensitivities
  Regular consumption of dairy products
  (milk, cheese,cream, butter, ice cream) 		Recurrent yeast fungal infections
  Feeling low, uninterested, angry Weak bones, teeth or cartilage
  Too little sleep or restless sleep Suffer from anxiety or worry
  Menopausal concerns Easily irritated or angered
  Frequent urination or urinary concerns Do not exercise regularly
  Hair Loss Respiratory, sinus or allergy problems