Title
First name *
Last name *
Birth Date *
Country
Marital
Marital
Single
Married
Separated
Divorced
Widowed
Cohabitation
Email address *
Phone number
Number of Guests
Clients Vital Information
What Is Your Blood Pressure/ Pulse Left Side:
What Is Your Blood Pressure/Pulse Right Side:
Current weight
Ideal weight
Height
Respiration rate:
Saliva PH:
Urine PH:
Basel Temperature:
Genetic / Family Medical History:
Personal Medical History:
Injuries and Operations:
Chemical Non-Prescription Medications / Quote Times and Dosages. Reason for taking?:
Natural Prescription Supplements / Quote Times and Dosages. Reason for taking?:
Have you done or are you currently in treatment:
Intake of Stimulants or Depressants:
If Any Of The above, Describe And when Last Taken?:
Important Health Questions
Do you have or have you had any of the following?:
If you answered yes to any of the above questions, please explain:
Thyroid/Parathyroid (Glandular System)
Adrenal Glands (Glandular System) Medulla (Adrenal)
Do you have any 'itis's (inflammatory conditions) Which :
Adrenal Glands (Glandular System) Medulla (Adrenal)
Have you had a hysterectomy? Surgical tissue removal operation on the uterus. Date? Was it partial or complete?:
Did they take any other organs out at the same time? (i.e.: gallbladder? Any other organs?:
Have you had a D&C? (Removal of abnormal tissue from the inner lining of your uterus?) If yes, Date?:
Have you been on birth control pills? For how long?:
Are you currently pregnant? For how long?:
Are you currently breastfeeding? For how long?:
Have you experienced a miscarriage or termination?:
Do you have prostatitis (swelling and inflammation of the prostate gland)? (Frequent urination, especially at night? If yes, how often do you urinate?:
Do you have prostate cancer? What are your PSA counts?:
Adrenal Glands (Glandular System) Medulla (Adrenal)
Do you have or have you had any type of Gastro-Intestinal Cancer? (stomach, colon, rectal, Etc...):
Do you have other Gastro-Intestinal Problems?:
What are your bowel movements like? 0,1,2,3 or more times a day.
Liver / Gallbladder / Blood
Do you have heart arrhythmias? What Kind, to slow, to fast, irregular?:
Do you get prickly pains, anywhere? especially in the heart area? Where?:
Do you itch anywhere? Where?:
Do you have skin problems? If so, what type?:
Part 9:/ Tick the boxes if yes
I have hair loss, or I am bald or getting bald. I had lymph nodes removed. I have or had a goiter (Inflammation of the thyroid). I have gray hair. I have a hard time remembering things. I get colds or flu-like symptoms. I have fibromyalgia (characterized by widespread musculoskeletal pain, accompanied by fatigue, sleep, memory, and mood issues) or scleroderma (hardening of connective tissue). I have sinus problems. I have a sore throat or easily get sore throats. I have swollen lymph nodes. I have a low platelet count. My immune system is weak or sluggish. I get a boil, pimples, cysts, etc. I have or had abscesses. I have or had toxemia (Blood poisoning by toxins from a local bacterial infection). Do have or had cellulitis (Potentially serious bacterial skin infection, swollen, hot, tender skin area that can easily spread to other parts of the body). I Have or had gout (A form of inflammatory arthritis characterized by current attacks of the red, tender, hot, and swollen joint). I get blurred vision. I have rheum in my eyes when I wake up in the morning. I snore. I have sleep apnea (One or more pauses in breathing or shallow breaths while you sleep). I exercise. I exercise a lot.
Do you have or have you had tumors? If so, where? Fatty? Benign? Malignant?:
Have you had appendicitis (Inflammation) or an appendectomy (Surgical removal)? when?:
Have you had your tonsils (collections of lymphoid tissue) out? What age?:
Are you on inhalers or nebulizers? How often and what type?:
Your oxygen saturation level is? If you have lung disease or other types of medical conditions, fewer of your red blood cells may be carrying their usual load of oxygen, 95%-100% of red blood cells passing through the lungs should be saturated.:
Are you a smoker? How often? How many packs of cigarettes a day?:
Are you affected by secondhand smoke or environmental smoke and exhaust fumes from cars, ferries, etc... :
Have you had radiation? Chemotherapy? If so, how many treatments?:
Have you been exposed to nuclear wastes or by-products, heavy metals, or chemicals?:
Do you have any allergies? (Food, chemicals, etc...):
What are your major health complaints and concerns? Are there any not covered in this questionnaire?:
Describe your professional life, do you like it, love it, or are in need of a change?
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