Name

Age

Height

Weight

What kind of exercise do you do/how often?

What are your favorite hobbies/ things to do?

 

Medications

 

Supplements

 

Health concerns and conditions

 

 

 

 

Dental Health and do you currently have mercury amalgams?

 

Typical diet

 

Breakfast

 

Lunch

 

Dinner

 

snacks

 

Brief Medical History and issues

 

 

Sleep quality 1-10   ____________

 

When do you typically go to sleep?

 

Wake up?

 

How refreshed do you typically feel 1-10  ______________

 

Occupation and work environment (describe it please)

 

How much do you drive?

 

How much do you work?

 

Have you detoxed your home?

 

Do you use any EMF protection?

 

Do you use a cell phone or cordless phone? Are you aware of the safe ways to use it?

 

Do you use artificial light?         Blue Light Blocking glasses or bulbs?

 

 

Please tell me anything about your life that might help me get a picture of your situation so I can better assist you in your goals. Or anything you would like to share.