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Registration Number: _______________ Date: __________
(Above fields for office use only)
Personal Information


Full Name:
Date of Birth:
Email Address:


Address:
City:
State:
Zip:

Daytime Phone:
Evening Phone:
Cellular/Mobile Phone:


Sex: Age: Years
Height Weight
Diet Smoking Alcohol
Any Weight in


Your Profession

Profession:
Job Responsibilities:
Exposure to Computers: Years: Hrs/Day:
Exposure to Chemicals at place of work at any time in the past?
If yes, Describe :
Work Address:



If you are female ...



Check each symptom given below that apply to you:

PMS / Cramps
Menopausal symptoms
Headaches / Migranes
Mood swings / Depression
Inability to lose weight
Fatigue
Foggy thinking / Memory loss
Lost interest in sex
Water retention / bloating
Low blood sugar
Adult acne
Lower Back Pains
 Irregular Cycles
Lowered Libido
Breast Tenderness
Panic / Weeping
Blood Sugar Imbalance
Leg / Muscle Cramps
Feeling of being crazy
Hysteria
Allergies
Facial Hair
Low Thyroid Symptoms
Sciatica (Lower Back / Leg Pain)

Hot/Cold Flashes
Bone Loss
Swollen Feet / Ankle
Vaginal dryness
Hair loss
Fibrocystic Breast
Anger / Irritability
Uterine fibroids
Age and Liver Spots
Dry aging skin
Insomnia
Spondylitis (Upper Back Pain)

Any Others:

Age at Menopause:
Age at Hysterectomy:
Age at Puberty:

Do you have, Irregular Periods / Non-Ovulating Cycles / Have the number of days of flow reduced to less than typical 4 day period normally encountered in most women.
If so, explain:

 


If you are male ...


Check each symptom given below that apply to you:

Difficulty Passing Urine
Impotence
Prostate Inflammation
Headaches / Migranes
Mood swings / Depression
Inability to lose weight
Fatigue
Foggy thinking / Memory loss
Lost interest in sex
Water retention / bloating
Low blood sugar
Adult acne
Reduced Muscular Strength
Lower Back Pains
 Enlarged Prostate
Erectile Dysfunction
Irregular Cycles
Lowered Libido
Burning Sensation Urinating
Panic / Weeping
Blood Sugar Imbalance
Leg / Muscle Cramps
Feeling of being crazy
Hysteria
Allergies
Swollen Feet / Ankle
Low Thyroid Symptoms
Low Sperm Count
Sciatica (Lower Back / Leg Pain)

Incontienence
Lack of Sex Drive
Prostate Cancer
Breast Enlargement
Hair loss
Hypoglycemia
Anger / Irritability
Bone Loss (Osteoporosis)
Age and Liver Spots
Dry aging skin
Insomnia
Diabetes
Spondylitis (Upper Back Pain)

Any Others:

Enlarged Prostate:
If yes, explain:



Misc. Medical Information for Males & Females


If you have weak eyesight, tell us about it:

Your Medical History :

History of Constipation / Impotence / Lack of Sex Drive / Urinary Problems:

Present Symptoms:

Chronic Health / Beauty Challenges you would like to overcome:

 

Please provide a list of medications that you presently take

 

Brand Name
Chemical Name
Tablet Size
(mg)
Dose
Duration
(Years / Months)
For What Ailment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

 

 

Referred to our Health Center by:
(Name of Doctor, Clinic, Individual, or Publication where you heard about us.)

 

Disclaimer
By submitting this questionnaire and filling out my full name with today's date below, I certify that the facts herein are true and correct. I am willing to participate in any Program you may have for my Chronic Health / Beauty Challenges through Natural means. I understand that the Programs offered are not intended to replace Conventional Medicine, but rather to complement and enhance it. If symptoms persist or are severe, I will consult a competent medical professional immediately. I understand that all Health and Beauty Care Counseling I receive is given to me with the best of intentions and are unlicensed healing arts services in the State of California (Business and Professions Code sections 2053.5 and 2053.6). I assume all responsibilities for my actions today and in the future and hold all others harmless.

Full Name: Today's Date:

 


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