Consult Our Doctors

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Please take a few minutes to complete the following questions.

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First Name * Last Name * Email* Phone Number * Age * Sex * Occupation

List current health problems for which you are being treated *

What types of therapies have you tried for these problem(s) or to improve over-all * Diet modification Fasting Vitamins/minerals Herbs Homeopathy Chiropractic Acupuncture Conventional drugs Other   If other please explain

Current Medications *

Major Hospitalization, Surgeries, Injuries: Please list procedure, complications (if any) and dates

Tell us level of stress you are experiencing, from 1 to 10 (1 being the lowest) *

What are your current health goals *

Do you experience any of these general symptoms Every Day Debilitating fatigue Depression Disinterest in sex Disinterest in eating Shortness of breath Panic attacks Headaches Dizziness Insomnia Nausea Vomiting Diarrhea Constipation Fecal incontinence Urinary incontinence Low grade fever Chronic pain/inflamatin Bleeding Discharge Itching/rash

Other Symptons

Head Eyes Ears Nose Joints/Muscle Headaches Faintness Dizziness Insomnia Watery or itchy eyes Swollen red or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision Itchy ears Earaches ear infections Drainage from ear Ringing in ears hearing loss Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness           Skin Heart Lungs Digestive Tract Mouth/Throat Acne Hives rashes dry skin Hair loss Flushing hot flashes Excessive sweating Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain Chest Congestion Asthma bronchitis Shortness of breath Difficulty breathing Nausea vomiting Diarrhea Constipation Bloated feeling Belching passing gas Heartburn Intestinal/stomach pain Chronic coughing Gagging frequent need to clear throat Sore throat hoarseness loss of voice Swollen or discolored tongue gums or lips Canker sores           Weight Energy/Activity Emotions Mind Other Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight Fatigue sluggishness Apathy lethargy Hyperactivity Restlessness Mood swings Anxiety irritability nervousness Anger irritability aggressiveness Depression Poor memory Confusion poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disability Frequent illness Frequent or urgent urination Genital itch or discharge

Health Habits

Tobacco Cigarettes per day: Cigars per day:       Alcohol Wine glasses per day or week: Liquor ounces per day or week: Beer bottles per day or week:   Caffeine Cups of Coffee per day: Cups of Tea per day: Soda w/ Caffeine per day:   Water Glasses of Water per day:

Medical History

Arthritis Allergies/hay fever Asthma Alcoholism Alzheimer's disease Autoimmune disease Blood pressure problems Bronchitis Cancer Chronic fatigue syndrome Carpal tunnel syndrome Cholesterol elevated Circulatory problems Colitis Dental Problems Depression Diabetes Diverticular disease Drug addiction Eating disorder Epilepsy Emphysema Eyes ears nose throat problems Environmental sensitivities Fibromyalgia Food intolerance Gastroesophageal reflux disease Genetic disorder Glaucoma Gout Heart disease Infection chronic Inflammatory bowel syndrome Irritable bowel syndrome Kydney or bladder disease Learning disabilites Liver or gallbladder disease (stones) Mental illness Mental retardation Migraine headaches Neurological problems (Parkinson's paralysis) Sinus problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia Sexually transmitted disease Seasonal affective disorder Skin problems Tuberculosis Ulcer Urinary tract infection Varicose veins Current Supplements Multivitamin/mineral Vitamin C Vitamin E EPA/DHA Evening Primrose/GLA Calcium Calcium source: Magnesium Zinc Minerals Mineral source: Friendly flora (acidophilus) Digestive enzymes Amino acids CoQ10 Antioxidants (e.g. bee pollen phytonutrient blends) Liquid meals (Ensure) Men Benign prostatic hyperplasia Prostate cancer Decreased sex drive Infertility Sexual transmitted disease Women Menstrual irregularities Endometriosis Infertility Fibrocystic breasts Fibroids/ovarian cysts Premenstrual syndrome (PMS) Breast cancer Pelvic inflammatory disease Vaginal infections Decreased sex drive Sexually transmitted disease Changes menstrual flow: Surgical menopause Menopause Date last GYN exam: Mammogram + - PAP + - Form of birth control: Family Health History Arthritis Asthma Alcoholism Alzheimer's disease Cancer Depression Diabetes Drug addiction Eating disorder Genetic disorder Glaucoma Heart disease Infertility Learning disabilities Mental Iliness Mental retardation Migraine headaches Neurological disorders (Parkinson's paralysis) Obesity Osteoporosis Stroke Suicide Stress Mental Emotional Learn how to reduce stress Think more clearly and be morefocused Improve memory Be less depressed Be less moody Be less indecisive Feel more motivated Eating Habits Skip meals Skip which meals: One meal/day Two meals/day Three meals/day Graze (small frequent meals) Generaily eat on the run Eat constantly whether hungry or not Body Composition Loose weight Burn more body fat Be stronger Have better muscle tone Be more flexible Exercise 5-7 days per week 3-4 days per week 1-2 days per week 45 minutes or more duration per workout 30-45 minutes duration per workout Less than 30 minutes Walk Walk – days per wk: Run, jog, other aerobic Run – days per wk: Weight lift Weight lift – days per wk: Stretch Stretch – days per wk: Nutrition & Diet Mixed food diet (animal and vegetable sources) Vegetarian Vegan Sait restriction Fat restriction Starch/carbohydrate restriction The zone diet Total calorie restriction Specific food restrictions Dairy Wheat Eggs Soy Com All gluten Food Frequency Number of servings per day: Dark green or deep yellow/orange vegetables Fruits (citrus, melons, etc.) Grains (unprocessed) Beans, peas, legumes Dairy, eggs Meat, poultry, fish Life Enrichment Reduce my risk of degenerative disease Slow down accelerated aging Maintain a healthier life longer Change from a "treating-illness" orientation to creating a wellness lifestyle Energy - Vitality Feel more vital Have more energy Have more endurance Be less tired after lunch Sleep better Be free of pain Get less colds and flu Get rid of allergies Not be dependent on over the counter medications like aspirin ibuprofen anti-histamines sleeping aids etc. Stop using laxatives and stool softeners Improve sex drive

Final Comments & Submit

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