Choose One : Choose One : Digestion - Intestines IBS Irritable Bowl Syndrome Allergies Lyme Disease Depression / Burn-Out High Blood Pressure Others

Choose one or many symptoms below: Choose one or many symptoms below: Burning in the stomach or upper abdomen Abdominal pain Bloating (feeling of fullness) Belching and gas Nausea and vomiting Acidic taste Growling stomach

Choose one or many symptoms below: Choose one or many symptoms below: Belly pain Constipation Diarrhea Cramps Bloating Persistent pain Frequent washroom trips

Choose one or many symptoms below: Choose one or many symptoms below: Runny Nose Stuffy Nose Sneezing Wheezing Shortness of Breath Cough Rashes Fatigue Headache Nausea and Vomiting Fever

Choose one or many symptoms below: Choose one or many symptoms below: Fever Chills Sweat Muscle aches Fatigue Nausea Joint pain Bell’s palsy (facial drooping)

Choose one or many symptoms below: Choose one or many symptoms below: Feelings of helplessness Feeling of hopelessness Loss of interest in daily activities Appetite (Changes) Weight (Changes) Sleep changes Anger or Irritability Loss of energy Self-loathing Reckless behavior Concentration problems Unexplained aches and pains

Choose one or many symptoms below: Choose one or many symptoms below: Severe headache Fatigue or confusion Vision problems Chest pain Difficulty breathing Irregular heartbeat Blood in the urine Pounding in your chest Pounding in your neck Pounding in your ears

Enter your specific ailment here.

What do you believe caused these symptoms?

What would you like to achieve for your health ?

My daily diet typically consists of?

Activity Levels? Activity Levels? Exercise Daily (Very Active) Exercise Weekly (Moderately Active) Very Little Exercise (Sedentary lifestyle)

General Conditions? General Conditions? Fatigue Hyperactivity Insomnia Restlessness

Other known conditions? Other known conditions? Allergies Body Pain Other Sensitivities Other Restrictions

Elaborate on your allergies (Optional).

Elaborate on your body pain (Optional)

Elaborate on your sensitivities issues (Optional).

Elaborate on your Restrictions (Optional).

Any stress lately? Any stress lately?Yes, Very HighYes, Medium & ManageableNone

Elaborate more on the stress issue

Any anxiety lately? Any anxiety lately?Yes, Very HighYes, Medium & ManageableNone

Elaborate more on the anxiety issue

Anything else you would like to share?

First Name

Last Name

johndoe@email.com

DD DD12345678910111213141516171819202122232425262728293031

MM MM123456789101112

Year Year2014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924