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*Please read the following DISCLAIMER before filling out your profile.


Please complete each section in order to best assess what program we can recommend to you. All information will be maintained as strictly confidential.

Please ensure that all marked areas are filled out before submitting.

Personal Profile

 
*Name: Occupation:
*Address: Date of Birth:
*City: Physician:
*Province/State: Date of Last Visit:
*Postal/Zip Code: Reason for Visit:
*Tel 1: Sex:    F 
Tel 2: Marital Status:    M     D     W 
Fax: No. of Children:
*e-mail:    
 

Health Profile

 
Lack of energy / fatigue
Stress Problems
Feelings of Anxiety
Depression
Headaches
Vision problems
Congestion
Sinus pain
Insomnia
Sweats
Chronic cough
Frequent colds / flu
Allergies
Asthma symptoms
Exposure to chemicals / herbicides / pesticides
Chest pains
Ear aches
Abdominal discomfort
Indigestion
Nausea
Constipation
Bloating
Diarrhea
Flatulence
Stomach ulcers
Excessive hunger
Yeast problems
Liver problems
Rapid weight loss
Excessive weight gain
Loss of appetite
Low blood pressure
High blood pressure
Cold feet / hands
Bruising
Numbness
Painful urination
Low back pain
Water retention
Kidney problems
Discolored urine
Prostate problems
Erectile dysfunction
Joint pain / stiffness
Muscle aches / pains
Skin problems
Hair loss
PMS symptoms
Irregular menses
Menopause
Loss of sexual libido
Are you pregnant or nursing
 

Lifestyle Considerations

 
Do you:
Drink alcoholic beverages
Smoke or ever smoked
Eat high fat foods (meat, deep fried foods)
 
Drink caffeine (soda, coffee) 3 times a week
Exercise 2-3 times per week
 

Medical History

 
Are you or have you ever been treated for: (inc family members)
Stress or depression
Diabetes
Heart disease / hypertension
Acne / psoriasis / other skin disorders
Bowel problems
Liver disorders, hepatitis
Menopause / HRT
Cancer
Allergies / asthma or bronchitis
Arthritis (rheumatoid or osteo)
Any other conditions
Please list conditions
 

Medication History

 
Please list all current pharmaceutical drugs
Please list all current vitamins, herbs, or food supplements
 

Areas of Concern

 
Comments and areas of concern
 
We appreciate the opportunity to discuss your problems and concerns. We wish to make it clear that our intent is not to diagnose or prescribe, but to offer recommendations and information to help you establish a healthy order in your daily life. If you seek medical advice, please consult a medical practitioner. If you seek a diet, please consult a registered dietitian. If you are seeking ways to take responsibility for your own health and well being, we are happy to be of assistance.


       

 

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