** None Female Male
Physical Activity Level
** None No Exercise Some Exercise Moderate Exercise Atheletic
** None Married Separated Divorced Widowed Single Partnership
Hours per week
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Number
Emergency Contact Address
How did you hear about our Wellness and Nutrition Program?
What is your major health concern. Please list when each symptom began and be as descriptive as possible
What are your current medications, how long have you been on them and what health issues were they addressing?
What are your current vitamins and/or supplements?
What hobbies do you, or have you enjoyed?
Please list your current and past health conditions (i.e. Diabetes Mellitus, etc.)
Is there anything else in your medical history that you consider to be relevant? (Even from childhood)
What is your employment history? Please provide brief summary including dates if possible.
Please list past or present allergies, including allergies to medications.
Please list all past surgeries and the condition treated, including dates.
Please explain your housing history (type of homes, where and when).
Answer the following questions to the best of your ability. If you don't know the answer, simply leave it blank.
Do you have amalgam (silver) fillings in your teeth? If yes, How many? _______
Have you ever had an amalgam removed? If Yes, How many?______
If you had amalgams removed, was it done by a biological dentist using a safe protocol?
Did your mother have amalgam when pregnant with you?
Have you ever worked in a dental office? If so, how long? ____________
Have you had any dental crowns? If yes, how many_____
Have you had any bridges?
Have you had any root canals?
Have you had any tooth extractions?
Do you have any dental implants, retainers or other metal in your mouth? Explain:_______
Did you wear contact lenses during the 1980’s or early 1990’s?
Did you take oral contraceptives during the 1980’s or early 1990’s?
Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?
Have you noticed any adverse reactions to these shots?
Do you have any tattoos with red ink?
Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?
Does your occupation involve soldering or metal salvage?
Have you done any old home repair or sandblasting? If so, When_______
Do you do a lot of painting?
Was your home built before 1978?
Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)
Are you around a lot of fake leather, or vinyl?
Do you get stomach aches in the morning?
Have you ever lived near, on or by a golf course, freeway or tension wires? If yes, please explain.
Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)
Do you have your house sprayed with pesticides for pest control?
Do you spray herbicide (weed killers) in or around your home?
Do you use conventional insect repellants on yourself or family?
Do you use conventional sunscreen?
Do you use conventional perfume or cologne every day?
Do you get your hair colored? If so, is it on the scalp?
Do you use aerosol hairspray?
Do you get your nails done? If so, how often? _____________
Do you use air freshener in your house, work or car?
Do you drink filtered water? If so, what type of filter do you have?_________
Do you drink bottle water, If so what kind?________
Do you have a water filtration system for your entire house or shower filtration? If so, what type?________
Does your spouse or other family members work around chemicals?
Can you think of any other toxic exposures you may have had? Explain:__________
How old is the house you are living in?
How long have you lived there?
Have you noticed any new symptoms since moving in?_________ If so, what?___________________________
Do you see mold growing at home, work or school?
Have you ever had water damage at home, work or school?
Does your home, workplace or school have a damp or mildew smell?
Does spending time in your basement cause or worsen your symptoms?
Does your basement ever get wet?
Do you have a crawl space?
Does your basement or crawl space have a sump pump?
Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?
Does your car have a mildew smell?
Does anyone in your home have asthma like symptoms?
Does anyone in your family have chronic sinus infections or irritations?
Have you ever been diagnosed with Lyme Disease?
Have you had dry sockets or infected tooth extractions?
Do you have small joint pain?
Have you ever been bitten by a tick or recluse spider?
Have you ever seen a bulls-eye rash appear on any part of your body?
Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?
Was your mother ever diagnosed with Lyme Disease?
Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?
Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?
Does anyone in your family experience similar symptoms to yours?
What is your birth order (i.e. first born, second, third, etc.)?
Do you have any history of kidney dysfunction?
Do you or any immediate family member have a history with cancer?
Do you have any history of heart disease, myocardial infarction (heart attack), etc.?
Are you currently having any thoughts of suicide?
Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?
Do you have a history of strokes?
Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?
Do you or anyone in your family have an autoimmune disorder?
Have you ever been in an auto accident, fallen or received a major physical injury?
Are you in menopause?
Do you get foul or sulfur smelling gas (distention, bloating, belching, feeling full and a noisy gut) after eating carbohydrates (ie. grains and vegetables) or fermented foods and/or probiotics?
Do you often have gas that has a sulfur or foul smell?
Are you sensitive to supplements?
Have you ever been vegan or vegetarian for any length of time?
Can you tolerate meat?
Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?
Have you taken birth control or Hormone Replacement Therapy for any length of time?
If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?
Have you been on antibiotics for any extended period of time or often as a child or adult?
Were you caesarian delivered?
Were you breast fed? If so, How long ______________
Does your gut temporarily feel better after a round of antibiotics?
Do you have a daily bowel movement? If so how many times per day? ________
Other Forms or Blood Work Results