Primary problem you want to address:
List any prescription medications currently taken:
What is your blood type? (O, A, B, AB)
List nutritional supplements currently taken:
Difficulty focusing or concentrating
Body temperature low, often colder than others in the same room
slow rate of speech and/or requires others to speak slowly or repeat themselves often
Fall asleep when head hits the pillow
Slow starter in the morning
limp or flat hair that won't hold a curl
Poor hand-eye coordination or difficulty with directions
Poor memory, need to write things down, or walk into a room and forget why you're there
difficulty learning new information/skills, or lives in past and tells the same stories over and over
Trouble seeing someone else's point of view
Outer 1/3 of eyebrow thinning or absent; or pencil-thin or penciled-on eyebrows
Sweats often or heavily or oily skin
Frontal headaches or headaches at base of skull
Night sweats, wake between 1 - 3 am, or wake up exhausted
Belches or burps after meals
Tans easily, dark skin even in winter months
Water retention or puffiness in fingers, toes, or cheeks
Swollen tongue with teeth marks around edges
# of times sick with flu, shingles, or other virus in your lifetime
# of times sick with ear infection, strep throat, staph, or other bacterial infection in your life
# of time you missed school or work 2 times or more per year from illness in past 10 years
Spider veins, varicose veins, or hemorrhoids
low vitamin D on blood tests
yellow stains in armpits of white shirts
Eyebrows thinning from top to bottom
Intestinal gas, especially after consuming leafy green vegetables
Cherry-colored markings on skin (check chest, neck, underarms, and belly) How many do you count?
Constipation or straining during bowel movements
Stores fat mainly in mid-section
Bloating (in general or with certain foods)
Pebbles, or thin, ribbon-like stools
Cravings for starches like potatoes, pasta, bread, rice, cereal
female: peach fuzz on cheeks or upper lip hair
female: heavy period, 5+ days, cramping, and/or PMS or migraines
# of times on an antibiotic in your life
Eczema or other patches of lighter skin color
Itchy, irritated, or dry skin
Water retention in ankles, "sock rings" at the end of the day
Restless sleep, lots of dreaming, usually about home/work
Overheat easily during exercise often with very red face/cheeks
Cellulite formation or skin dimpling around buttocks, upper thighs, or arms
Hold body stiffly or rigidly, or can't support body and sags
Age spots or bronze discolorations on skin and/or many freckles
makes poor food choices when hungry, tired, or emotional
store fat mainly in hips, buttocks, or thighs
reduced appetite during day, may increase at night
How many cups of coffee do you drink per week?
How many cups of caffeinated tea do you drink per week?
How many alcoholic drinks do you have per week? (1 shot = 1 drink, 1 glass of wine = 1 drink, 1 beer = 1 drink)
How many days per week do you eat chocolate?
Any known food allergies or sensitivities?
Describe your sleep quality (terrible, poor, average, great)
How many nights per week do you sleep through the night without waking up?
Do you remember your dreams? Do you have nightmares?