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Health Intake Questionnaire

First Name *

Last Name *

Phone *

Email *

Address *

Street Address

City

State

Country

Postal Code

Birth Date *

Birth Place *

Height *

Weight *

Gender *

Occupation *

Referred by *

Today's Date *

Describe Health Related Problems/Symptoms: *

What treatments have you tried? *

Has anything been successful? *

Have you lived or traveled outside of the United States? If so, when and where? *

How much time have you lost from work or school in the past year? *

Please list any allergies or intolerances (food or environmental): *

List past Medical and Surgical History: *

List previous hospitalizations: *

How often have you taken antibiotics? *

How often have you taken oral steroids? *

What medications are you taking now? (including birth control/hormones) *

List all vitamins, minerals, and other nutritional supplements that you are taking now. *

What is your typical daily diet: *

How much tea do you consume each week? *

How much coffee do you consume each week? *

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)? *

How many bowel movements (BM) 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? *

Do you have mercury amalgam fillings in your teeth? If so, how many? *

Do you have any artificial joints or implants? If so, which ones? *

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

How would you rate your current level of stress? *

Women: If you have a cycle, how long is it and is it regular? *

Women: Any other comments related to your cycle? (flow, clots, mood changes, etc.) *

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: *

Please add any other information you feel is important: *

Congratulations, you are on the path to taking your first step towards health and wellness!

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I have read and understand everything on this page. I acknowledge that and its associates provide support and do not diagnose, cure, or treat any illness or disease. Furthermore, the undersigned releases , its partners, contractors, affiliates, and representatives from any and all liability for any failure to identify or address any medical condition or disease. It is understood and agreed that this is not the purpose of their services.

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Restoration Integrative Health & Wellness

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