Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate
*
MM
DD
YYYY
Birthplace
*
Height
*
Weight
Gender
Occupation
Today's Date
MM
DD
YYYY
Describe Problem(s):
*
What treatments have you tried?
*
Has anything been successful? Unsuccessful?
*
With whom do you live?
*
Do you have any pets or farm animals? If yes, where do they stay?
*
Have you lived or traveled outside of the US? If so, when and where?
*
Have you or your family recently experienced any major life changes? If yes, please comment:
*
Have you experienced any major losses in life? If so, please comment:
*
How much time have you lost from work or school in the past year?
*
Previous jobs:
*
Did you feel safe growing up?
*
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
*
Do you feel safe, respected, and valued in your current relationship?
*
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
*
Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues?
*
List past Medical and Surgical History:
List previous hospitalizations:
*
How often have you taken antibiotics?
*
How often have you have taken oral steroids?
*
What medications are you taking now?
*
Were you a full-term baby? A preemie? Breast-fed or bottle-fed?
*
As a child did you eat a lot of sugar and/or candy?
*
What is your typical daily diet:
*
How much of the following do you consume each week?
Tea
1-3 cups
3-5 cups
5+ cups
0 cups
Coffee
1-3 Cups
3-5 Cups
5+ Cups
0 cups
Soda
1-3
3-5
5+
0
Other Caffeine
1-3 times
3-5 times
5+ times
0 times
Dairy
*
Never
Rarely
Occasionally
Often
Cheese
Never
Rarely
Occasionally
Often
Bread
Never
Rarely
Occasionally
Often
Sugar
Never
Rarely
Occasionally
Often
Candy/ Chocolate
Never
Rarely
Occasionally
Often
Dessert
Never
Rarely
Occasionally
Often
Are you on a special diet?
*
specify type
Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with a particular food or supplement(s)?
*
Do you feel worse when you eat certain foods?
*
Which foods?
Have you ever had a food that you craved or really "binged" on over a period of time?
*
Do you have an aversion to certain foods? If yes, what foods?
*
How many bowel movements do you have per day?
*
Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?
*
Do you have intestinal gas? If so, when?
*
How many times per week do you drink alcohol?
Have you ever used recreational drugs?
Have you ever used tobacco?
*
(If so, for how long?)
Are you exposed to secondhand smoke regularly?
Do you have mercury amalgam fillings in your teeth?
*
If so, how many?
Do you feel worse at certain times of the year?
*
Have you, to your knowledge, been exposed to toxic metals in your job or at home?
*
Do odors affect you? If so, which ones?
How would you rate your current level of stress?
*
Have you ever had psychotherapy or counseling?
*
Are you currently, or have you ever been, married?
List your hobbies and leisure activities:
Do you exercise regularly? If so, how many times a week?
What type of exercise is it?
Do your parents or siblings have (or had) any health issues? If so, please explain:
Patient Signature
*
I have read and understand everything on this page. I acknowledge Emily Gardner and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Emily Gardner, her lab partners, her independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.
