Your Name (required)

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Your Cell Phone (required – enter all 0s if you don’t have one)

Your Landline (required – enter all 0s if you don’t have one)

Sex (required)

Age (required)

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Career (required)

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Primary Symptoms and Concerns

Please provide a brief overview of your primary symptoms and concerns, including any diagnoses you may have.

When did your symptoms begin?

Was there anything significant that occurred at the time symptoms began? (e.g. traveled to another country, had food poisoning, after surgery, after remodeling a home, after a bout of diarrhea or the flu, after dental work, after an antibiotic, strep or other infection, etc.)

Medications

Please provide a list of current and past medications.

Nutritional Supplements & Herbs

Please provide a list of all nutritional supplements and herbs that you take currently.

Negative Response to Nutritional Supplements

Do you have a negative response to any nutritional supplements? If so, please list which ones and what kind of response.

Probiotics

Do you get worse on a probiotic? If so, please describe.

Lifestyle Factors

Do you smoke?

Do you use marijuana, including medical marijuana or cannabis oil?

Do you use any recreational drugs?

How often and how long do you exercise and what type?

How many hours of sleep do you typically get nightly?

How often do you spend time outdoors?

Any history of childhood abuse, neglect or trauma or loss of primary care giver? If so, briefly list type and extent (e.g. physical, sexual, emotional, neglect).

Any history of trauma as an adult?

Have you ever had a concussion or other trauma to the head?

Do you live environmentally friendly?

Do you use pesticides or herbicides in the home or the yard?

Do you live in an agricultural area, aerial spraying, or industrial area or near a highway?

Ever live on a farm or near a farm?

Do you have a Smart Meter on your house?

Have you had your appendix or gallbladder removed?

Have you ever traveled out of the country? If so, when and where?

Have you recently moved into a new home or done any recent remodeling?

Any visible signs of mold in your home (including odor)?

Do you feel worse in moldy environments or on damp or humid days?

Do you meditate? (Faithfully?) If so, how often?

Other

Do you have depression? (Where on a scale of 1 to 10)

Do you have fatigue? (Where on a scale of 1 to 10)

Do you have anxiety or panic attacks? (Where on a scale of 1 to 10) If so, how long have they been occurring?

Have you ever had food poisoning?

Do you have any gene mutations that you are aware of?

Anything Else?

Anything else you’d like me to know that we haven’t covered?

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