|
First Name, Last Name Current Street Address, City Address, State Address Current Country, Post Code Current phone #, Current email address Your Birth City, Birth State, Birth country Your Birth Date, Birth time (If known)
|
|
Are you Male or Female, Are you pregnant? What is your Height, Weight ?(Metric if possible, else imperial OK) Are there any inherited disease patterns in your family? (Backs, hearts, arthritis, allergy, cancer, etc)-Y/N Rate any negativity you may be feeling lately on a scale of 1 - 10? (1 is low, 10 is maximum neg.) Number of organs removed? (Two of a kind=1) ...App'x, tonsils, ovaries=1, etc Number of different prescribed (Doctor Based) drugs used currently? Number of times tobacco products used per day? Number of times steroid (cortisones or asthma preventers) used in the past year? Estimate the number of separate Dental Amalgam/Metal fillings present in your mouth OR past extracted? Number of times street drugs (non prescribed drugs) used in the past month? Number of all different known allergens? Number of known unresolved or ongoing mental factors or conflicts? On a scale of 1(min)-10(max), estimate how responsible you feel you are for your own health? Estimated % of fat in your whole diet? (The Av. western diet is around 30%) On a scale of 1(min)-10(max), estimate your current personal stress level? Number of times sugar sweetened (Include drinks, ice-cream, biscuits, cereals, etc) foods are eaten daily? Number of 20 minute exercise sessions per week? (Non work related) Average number of Alcohol containing drinks per day? Number of Caffeine (Includes tea, coffee, chocolate or CocaCola) serves per day? Number of known Toxic exposures (Radiation, Xrays, chemicals, insecticides, etc) this year? Number of Traumas (Loss, Marriage,etc) OR Major injuries in your life? Number of Major infections in your life?.. illnesses kept you at home for more than a wk or any Hospitalisations Average number of glasses of Water or juice daily? Number of Kilos overweight? |
|