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:
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