Name *
Today's Date *
Today's Date
Birthday *
Please provide more information about your diet, lifestyle and current medication use.
Alcohol *
Artificial Sweeteners *
Candy, desserts or refined sugar *
Tobacco products *
Caffeinated Beverages
Fast food *
Soda/Pop *
Diet or Regular
Fried Food *
Luncheon/processed meats *
Margarine/"butter" spreads *
Milk/Dairy Products *
Refined flour/ baked goods *
Vitamins and mineral supplements *
Diet often for weight control *
Check any and all medications you're currently taking or have taken in the last month
Upper GI
Belching or gas within one hour after eating *
Heartburn or acid reflux
Bloating within one hour after eating *
Vegan diet *
Bad Breath/Halitosis *
Loss of taste for meat *
Stomach upset by taking vitamins *
Sense of excess fullness after meals *
Feel like skipping breakfast *
Feel better if you don't eat *
Sleepy after meals *
Fingernails chip, peel or break easily *
Anemia unresponsive to iron *
Stomach pains or cramps *
Diarrhea, chronic *
Diarrhea shortly after meals *
Black or tarry colored stools *
Undigested food in stool *
Section 2
Pain between shoulder blades *
Stomach upset by greasy foods *
Greasy or shiny stools *
Nausea *
Sea, car airplane or motion sickness *
History of morning sickness/nausea *
Light or clay colored stool *
Dry skin, itchy feet or skin peels on feet *
Headache over eyes *
Gallbladder attacks *
Bitter taste in mouth, especially after meals *
Become sick if you were to drink wine *
Easily intoxicated if you drink wine *
Easily hung over if you drink wine *
Alcohol consumption per week *
on average
Recovering alcoholic *
History of drug or alcohol abuse *
History of hepetitus *
Long term use of prescription/recreational drugs *
Sensitive to chemicals *
i.e. perfume, cleaning agents, etc.
Sensitive to tobacco smoke *
Exposure to diesel fumes *
Pain under right side of rib cage *
Hemorrhoids or varicose veins *
Nutrasweet or Aspartame consumption *
Sensitive to aspartame *
Chronic fatigue or fibromyalgia *
Section 3
Food Allergies *
Abdominal bloating 1 to 2 hours after eating *
Specific foods make you tired or bloated *
Pulse speeds after eating *
Airborne allergies *
Experience hives *
Sinus congestion "stuffy head" *
Crave bread or noodles *
Alternating constipation and diarrhea *
Chrohns disease *
Wheat or grain sensitivity *
Dairy Sensitivity *
Are there foods you could not give up? *
Asthmas, sinus infections, stuffy nose *
Bizarre vivid dreams, nightmares *
Use of over the counter pain medications *
Feel spacey or unreal *
Section 4
Anus itches
Coated tongue *
Feel worse in moldy or musty place *
Taken antibiotic for a total accumulated time of *
Fungus or yeast infection *
Ring worm, "jock itch", athletes foot, nail fungus *
Yeast symptoms increase with sugar, starch or alcohol *
Stools are difficult or hard to pass *
History of parasites *
Less than one bowel movement per day *
Stools have corners or edges, are flat or ribbon shaped *
Irritable bowel or mucus colitis *
Blood in stool *
Mucus in stool *
Excessive foul smelling lower bowel gas *
Bad breath or strong body odors *
Painful to press along outer sides of thighs (IT band) *
Cramping in lower abdominal region *
Dark circles under eyes *
Section 5
History of carpal tunnel syndrome *
History of lower right abdominal pains or ileocecal valve problems *
History of stress fracture *
Bone Loss *
ie: reduced density on bone scan
Are you shorter than you used to be? *
Calf, foot or toe cramps at rest *
Cold sores, fever blisters or herpes lesions *
Frequent fevers *
Frequent skin rashes or hives *
herniated disc *
Excessively flexible joints "double jointed" *
Joints pop or click *
Pain or swelling in joints *
Bursitis or tendonitis *
history of bone spurs *
Morning stiffness *
Nausea with vomiting *
Crave chocolate *
Feet have a strong odor *
History of anemia *
Whites of eyes blue tinted *
Hoarseness *
Difficulty Swallowing *
Lump in throat *
dry mouth, eyes and/or nose *
Gag easily *
White spots on fingernails *
Cuts heal slowly and/or scar easily *
decreased sense of taste or smell *
Section 6
Experience pain relief with aspirin *
Crave fatty or greasy foods *
Low or reduced fat diet *
Tension headaches at base of skull *
Headaches when out in the hot sun *
Sunburn easily or suffer sun poisoning *
Muscles easily fatigued *
Dry flaky skin or dandruff *
Section 7
Awaken a few hours after falling asleep, hard to get back to sleep *
Crave Sweets *
Binge or uncontrolled eating *
Excessive appetite *
Crave coffee or sugar in the afternoon *
Sleepy in the afternoon *
Fatigue that is relieved by eating *
Headache if meals are skipped or delayed *
Irritable before meals *
Shaky if meals are delayed *
Frequent thirst *
Frequent urination *
Section 8
Muscles become easily fatigued *
Feel exhausted or sore after moderate exercise *
Vulnerable to insect bites *
Loss of muscle tone or heaviness in arms/legs *
Enlarged heart or congestive heart failure *
Pulse below 65bpm *
Ringing in ears *
numbness tingling or itching in hands and feet *
depressed *
Fear of impending doom *
Worrier, apprehensive, anxious *
Nervous or agitated *
Feelings of insecurity *
Heart races *
Can hear heart beat on pillow at night *
whole body or limbs jerk as falling asleep *
Night sweats *
Restless leg syndrome *
Cracks at corner of mouth *
fragile skin, easily chaffed *
Polyps or warts *
MSG sensitivity *
Wake up without remembering dreams *
Small bumps on back of arms *
Strong light at night irritates eyes *
Nose bleeds or bruise easily *
Bleed gums espeically when brushing teeth *
Section 9
Tend to be a night person *
Difficulty falling asleep *
Slow starter in the morning *
Tend to be keyed up, trouble calming down *
Blood pressure about 120/80 *
Headache after exercising *
Feeling wired or jittery after drinking coffee *
Clench or grind teeth *
Calm on the outside, troubled on the inside *
Chronic low back pain, worse with fatigue *
Become dizzy when standing up suddenly *
Difficulty maintaining manipulative correction *
Pain after manipulative correction *
Arthritic tendencies *
Crave salty foods *
Salt foods before tasting *
Perspire easily *
Get drowsy often *
Afternoon yawning *
Afternoonheadache *
Asthma, wheezing or difficulty breathing *
Pain on the medial or inner side of the knee *
Tendency to sprain ankles or get shin splints *
Tendency to need sunglasses *
Allergies or hives *
Weakness, dizziness *
Section 10
Height over 6'6" *
Early sexual development *
Puberty onset before age 10
Increased libido *
Splitting type headache *
Memory failing *
Tolerate sugar, feel fine when eating sugar *
Height under 4'10" *
Decreased libido *
Excessive thirst *
Weight gain around hips or waist *
Menstrual disorders *
Delayed sexual development *
Puberty onset after age 13
Tendency to ulcers or colitis *
Section 11
Sensitive or allergic to iodine *
Difficulty gaining weight, even with large appetite *
Nervous, emotional, can't work under pressure *
Inward trembling *
Flush easily *
Fast pulse at rest *
Intolerance to high temperatures *
Difficulty losing weight *
Mentally sluggish, reduced initiative *
Easily fatigued, sleepy during the day *
Sensitive to cold, poor circulation *
cold hands and feet
Constipation, chronic *
Excessive hair loss and /or coarse hair
Morning headaches, wear off during the day *
Loss of lateral 1/3 of eyebrow *
Seasonal Sadness *
Men Only
If you do not identify as male or feel that these questions do not apply to you, please skip to the next section.
Prostrate problems
Difficulty with urination, dribbling
Difficult to start and stop urine stream
Pain or burning with urination
Waking to urinate at night
Interruption of stream during urination
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Decreased sexual function
Women Only
If you do not identify as female or feel that these questions do not apply to you, please skip to the next section.
Depression during periods
Mood swings associated with periods
Crave chocolate around periods
Breast tenderness associated with cycle
Excessive menstrual flow
Scanty blood flow during periods
Occasional skipped periods
Variations in menstrual cycles
Uterine fibroids
Breast fibroids, benign masses
Painful intercourse
Vaginal discharge
Vaginal dryness
Vaginal itchiness
Gain weight around hips, thigh, and buttocks
excess facial or body hair
Hot flashes
Night sweats
in menopausal females
Thinning skin
Section 14
Aware of heavy or irregular breathing *
Discomfort at high altitudes *
Air hunger or sigh frequently *
Compelled to open windows in a closed room *
Shortness of breath with moderate exertion *
Ankles swell, especially at end of day *
Cough at night *
Blush or face turns red for no reason *
Dull pain or tightness in chest *
Muscle cramps with exertion *
Section 15
Pain in mid-back region *
Puffy around the eyes, dark circles *
History of kidney stones *
Cloudy, bloody or darkened urine *
urine has a strong odor *
Section 16
Runny or drippy nose *
Catch colds at the beginning of winter *
Mucus producing cough *
Frequent colds or flu *
Other infections *
Sinus, ear, lung, skin, bladder, kidney etc...
Never get sick *
Acne *
Itchy skin *
Cysts, boils, rashes *
History of Epstein bar, mono, herpes, shingles, chronic fatigue syndrome, or other chronic viral condition *