Personal Information

Address (required)

Email Address (required)

Please indicate the diagnosis for which you wish to be treated (required)

Your Health History

Health as a child was: (required)

GoodFairPoor

Childhood Illnesses:

Scarlet FeverGerman measlesPertussisMumpsRheumatic FeverChicken PoxDiphtheria

Other Illnesses (Past or Present):

TuberculosisAsthmaOsteoarthritisRheumatoid ArthritisPneumoniaTyphoidTonsillitisGonorrheaHypertensionHerpesEpilepsyDiabetesHay feverAlcoholismHeart DiseaseHepatitisMononucleosisKidney diseaseStrokeGlaucomaSLE (Lupus)Thyroid disorderInfertilityLyme diseaseDepressionNone of the Above

Hospitalizations (year and reason):

Surgeries (date and type):

Significant falls or injuries:

Serious Illnesses (year and cause):

Vaccinations (year, type, adverse reactions):

Present State Of Health

1. Able to carry on normal activity to work. No special care is needed: (required)

A. 100% Normal; no complaints no evidence of disease.B. 90% Able to carry on normal activity; minor signs of symptoms of disease.C. 80% Normal activity with effort; some sign or symptoms of disease.

2. Unable to work. Able to live at home and care for most personal needs. Assistance needed: (required)

A. 70% Cares for self. Unable to carry on normal activity or do active work.B. 60% Requires considerable assistance, but is able to care for most of oneself.C. 50% Requires considerable assistance and frequent medical care

3. Unable to care for self. Institutional care needed. Disease may be progressing rapidly: (required)

A. 40% Disabled; requires special care and assistanceB. 30% Severely disabled; hospitalization is indicated although death not.C. 20% Very sick; hospitalization necessary; active supportive treatment needed.

Please describe broadly your current diagnosis:

First symptoms: (required)

Evolution of the disease: (required)

Treatment prescribed by your Physician (including surgeries): (required)

Blood tests, MRI, CT Scans

Current condition: (required)

Family Current State Of Health (Age & Health State/Condition)

Mother: (required)

Father: (required)

Siblings: (required)

Spouse/Partner: (required)

Children: (required)

Please Check Family History Conditions:

CancerDiabetesHeart DiseaseHigh Blood PressureStrokeEpilepsyAsthmaMental IllnessHay-feverAlcoholismGlaucomaHivesKidney DiseasePhysical or Emotional AbuseTuberculosis

Other conditions not listed (Please specify):

Additional Medical Information

Prescription Medications: Include dosage and how long taken. (Attach sheet if needed)

Prescription Medications / Only PDF files are allowed

Non-prescription: Herbs and vitamins. (Attach sheet if needed)

Non-prescription / Only PDF files are allowed

Allergies: list any allergies or adverse reactions to inhalants, foods, medicines, perfumes, smoke, chemicals, etc.

Have you had an occupational or environmental exposure to noxious or hazardous substances? (required)

NoYes

Have you ever been exposed to any of the following?

1. Agricultural chemicals (pesticides, insecticides)? (required)

NoYes

2. Industrial/workplace chemicals? (required)

NoYes

3. Cigarette smoking? (required)

NoYes

4. Second hand smoke? (required)

NoYes

5. Alcohol use? (required)

NoYes

6. Recreational drugs? (required)

NoYes

7. Electromagnetic fields? (required)

NoYes

8. Other? Explain:

Habits

Do you use coffee? (required)

NoYes

Alcoholic beverages? (required)

NoYes

Tobacco: Do you smoke/chew? (required)

NoYes

Explain

General

Food Issues/Sensitivities

Gastrointestinal

Does food generally sit well in your stomach and digest without difficulty? (required)

YesNo

Are your bowel movements generally formed or loose? Color? (required)

How often do you have a bowel movement? (required)

Do you have gas or abdominal bloating? (required)

YesNo

Do you need to strain to have a bowel movement? (required)

YesNo

Do you have hemorrhoids or any other rectal or bowel problems? (required)

YesNo

If yes, please explain:

General Digestion Problems: Past & Present

Acid Indigestion (required)

YesNo

Acid Reflux (required)

YesNo

Colitis (required)

YesNo

Constipation (required)

YesNo

Diarrhea (required)

YesNo

Diverticulitis (required)

YesNo

Hiatal Hernia (required)

YesNo

Irritable Bowel Syndrome (required)

YesNo

Ulcers (required)

YesNo

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