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Health Assessment

    All collected information is confidential and will not be shared with any outside parties

    Basics
    What is your current address?
    When is your birthday?
    Where were you born?
    What is your gender?
    What is your marital status?
    What do you do for a living?
    What is your level of education?
    Wellness Goals
    What are your wellness goals?
    When was the last time you felt well?
    How motivated are you to make changes to your health
    Did something trigger your change in health?
    Personal Medical History
    All medical information is confidential and will not be shared with any outside parties
    Current medications
    Current supplements
    Do you currently or have you previously experienced any of the following? - select all that apply
    Irritable Bowel Syndrome
    Crohn's Disease
    Ulcerative Colitis
    Peptic Ulcer Disease
    GERD (reflux)
    Celiac Disease
    --- --- --- --- ---

    Heart Attack
    Heart Disease
    Stroke
    Elevated Cholesterol
    Arrhythmia (irregular heart rate)
    Hypertension
    Rheumatic Fever
    Mitral Valve Prolapse
    Other Heart Condition
    --- --- --- --- ---

    Type 1 Diabetes
    Type 2 Diabetes
    Hypoglycemia
    Metabolic Syndrome
    Hypothyroidism (low thyroid)
    Hyperthyroidism (overactive thyroid)
    --- --- --- --- ---

    Polycistic Ovarian Syndrome
    Infertility
    Weight Gain
    Weight Loss
    Eating Disorder
    --- --- --- --- ---

    Kidney Stones
    Gout
    Interstitial Cystitis
    Frequent Urinary Tract Infections
    Frequent Yeast Infections
    Erectile Dysfunction
    Sexual Dysfunction
    Herpes - Genital
    --- --- --- --- ---

    Osteoarthritis
    Fibromyalgia
    Chronic Pain
    Chronic Fatigue Syndrome
    Autoimmune Disease
    Rheumatoid Arthritis
    Lupus SLE
    Immune Deficiency Disease
    Severe Infectious Disease
    Poor Immune Function
    Food allergies
    environmental Allergies
    Multiple Chemical Sensitivities
    Latex Allergy
    --- --- --- --- ---

    Asthma
    Chronic sinustis
    Bronchitis
    Emphysema
    Pneumonia
    Tuberculosis
    Sleep apnea
    --- --- --- --- ---

    Eczema
    Psoriasis
    Acne
    Melanoma
    SKin cancer
    Other cancer
    --- --- --- --- ---

    Lung cancer
    Breast cancer
    Colon cancer
    Ovarian cancer
    Prostate cancer
    Skin cancer
    --- --- --- --- ---

    Depression
    Anxiety
    Pipolar Disorder
    Schizophrenia
    Headaches
    Migraines
    ADD/ADHD
    Autism
    Memory Problems
    Dementia/Alzheimer's
    Parkinson's Disease
    Multiple Sclerosis
    Seizures
    Other Mental Health
    --- --- --- --- ---

    Over The Counter Medication History - select all that apply
    NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
    Tylenol (Acetaminophen)
    Acid blockers (Tagamet, Zantac, Prilosec, etc.)
    Antibiotics
    Steroids
    Oral contraceptives
    --- --- --- --- ---

    What is your genetic background?
    Do you have any known drug allergies?
    What is your blood type?
    On average how many hours of sleep do you get each night?
    Please list any significant physical trauma you've experienced:
    Please list any significant emotional trauma you've experienced:
    Gynecological History
    All medical information is confidential and will not be shared with any outside parties
    Gynecological history - select all that apply
    Current use birth control - select all that apply
    Previous use birth control - select all that apply
    Patient birth history - select all that apply
    Patient breast feeding history - select all that apply
    Menopausal patients history - select all that apply
    Men's History
    All medical information is confidential and will not be shared with any outside parties
    Men's health history - select all that apply
    Dental History
    All medical information is confidential and will not be shared with any outside parties
    Family History
    All medical information is confidential and will not be shared with any outside parties
    Cancers
    Colon
    Breast/Ovarian cancers
    Heart Disease
    Hypertension
    Obesity
    Diabetes
    Stroke
    Inflammatory Arthritis
    Inflammatory Bowel Disease
    Multiple Sclerosis
    Autoimmune Disease
    Irritable Bowel Syndrome
    Celiac Disease
    Asthma
    Eczema/Psoriasis
    Food Allergies/Sensitivities
    Environmental Sensitivities
    Dementia
    Parkinson's
    ALS or other motor neuron disease
    Genetic Disorders
    Substance Abuse
    Psychiatric Disorders
    Depression
    Schizophrenia
    ADD/ADHD
    Autism
    Bipolar disease

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