3 Home Address
4 Phone Number
5 Follow up Phone Number
6 E-mail address
7 How did you hear about us?
9 What is your previous medical history?
10 Please list your top 3 goals and reasons for your visit to our website. You are welcome to list up to 5 wellness goals.
11.Have you ever had a surgical procedure?
a.What were the dates of your surgical procedures?
12 Are you allergic to any medications?
13 Are you allergic to any foods?
14 What prescription medications are you currently taking?
15 What over the counter vitamins/supplements are you currently taking? Please include doses
16.For women only – When was your last menstrual period?
b. Have you had a hysterectomy?
c. If so, do you still have one or both ovaries?
d. Are you currently taking birth control?
e. If so, please list what you are taking for birth control
f. How many pregnancies? Live births? Miscarriages?
g. If still menstruating, are menstrual cycles regular?
17. Have you or anyone in your immediate family been diagnosed with a thyroid disorder whether it is hypothyroidism or hyperthyroidism?
a. Do you suffer from fatigue?
b. Are you sometimes cold when others feel normal?
c. Do you have cold hands and feet?
d. Do you experience an afternoon slump in energy levels?
e. Are you experiencing weight gain or inability to lose weight despite weight loss efforts?
f. Do you have dry skin?
g. Do you have 2 or less bowel movements daily?
h. Are the outer third of your eyebrows missing or thinning?
i. Do you have hair loss or thinning hair?
j. Do you have dry, ridged, or brittle fingernails?
k. Do you suffer from joint stiffness especially in the morning?
l. Do you suffer from foggy memory?
m. Do you have high cholesterol?
18. Are you currently taking bio-identical hormone replacement?
a. Do you have low libido?
b. Are you sleeping well?
c. Are you having trouble falling asleep?
d. Are you having trouble remaining asleep?
e. Do you feel rested upon morning awakening?
f. Do you feel you have sufficient energy levels during the day?
g. Do you suffer from low mood or depression?
h. Do you suffer from lack of motivation or drive?
i. Do you find yourself having negative thoughts?
j. Do you suffer from inability to focus?
k. Do you feel lethargic?
19. Do you consider yourself stressed out by life?
a. Do you have a stressful life, work, or home environment?
b. Are you a business owner?
c. How many hours do you work weekly?
d. How many hours are you sleeping soundly per night?
e. Do you have the responsibility of either work or home deadlines?
f. Do you fall asleep readily, and awaken more than once throughout the night?
g. Do you find it hard to “turn off” your brain in order to go to sleep or fall asleep once awakened?
h. Once awakened at night, are you thinking/obsessing about what you have to do the next day?
i. Have you had what may be considered as a significant amount of weight gain over a limited amount of time such as in one year?
j. Are you experiencing weight gain/fat gain in your tummy/mid-section?
k. Are you experiencing an inability to lose weight despite diet and exercise efforts?
l. Are you having chest pain or tightness during activity or exercise?
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