Do you currently have a health problem or symptom that you would like addressed?*
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Yes
No
Please describe the frequency of your symptom(s)*
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Rare
Intermittent
Occasional but daily
Frequently everyday
Constant
Please indicate the intensity of your symptom(s)
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Mild
Annoying
Medium
Getting worse
Intense
Does your symptom(s) interfere with your daily activities?*
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No
Only occasionally
Can’t do certain activities
Frequently - all activities are restricted
Extremely limited in all activities
Whom have you seen already in an attempt to correct your health challenge or reach your health goals?*
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Primary Care physician
Chiropractor
Physical Therapist
Nutritionist
Naturopath
Functional Medicine Specialist
Medical Specialist (Orthopedist, Neurologist, Endocrinologist, etc.)
I have self-treated
I have done nothing at this point
Please indicate the outcome from any of the above.*
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No improvement
Slight or temporary improvement
25% improvement
50% improvement
75% improvement
ELIMINATION: If you are unable to urinate or defecate please indicate how long this is going on under "Other". This could be considered a medical emergency and should be dealt with as such.
2-3 BM's per day
1 BM per day usually
Often have diarrhea
Tend to be constipated
Often need laxatives to have a BM
If you are unable to urinate or defecate please indicate how long this is going on under "Other". This could be considered a medical emergency and should be dealt with as such.
DIGESTION: Choose ONLY ONE answer that best describes you.
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excellent, no complaints
occasional burping and/or intestinal gas
tend to get burping, heartburn, bloating, gas, indigestion
pain, leaky gut, Crohn's, reflux, ulcers, H.pylori
strong, frequent digestive complaints
WEIGHT: Choose ONLY ONE answer that best describes you.
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at ideal weight (weight that I look and feel best)
hard to maintain ideal weight
10 pounds overweight or underweight
very hard to lose weight
significantly overweight
EXERCISE: Choose ONLY ONE answer that best describes you.
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exercise every day
exercise 4-5 times a week
exercise 3 times a week
exercise 1-2 times a week
sedentary, rarely if ever exercise
How much water do you drink each day?*
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half my body weight in ounces
a gallon of water
a glass of water
I get my water primarily from coffee and tea
I don't drink any water
DAILY DIET: Choose ONLY ONE answer that best describes you.
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80-100% whole, natural organic foods
60-80% whole, natural organic foods
about 50% organic, 50% non-organic
little or no organic foods
often hungry, have cravings, for processed foods or sweets
SLEEP: Choose ONLY ONE answer that best describes you.
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sleep well, 7-8 hours per night
sleep OK, 6-7 hours usually
fall asleep but wake up and can’t go back to sleep
have trouble falling asleep
sleep problems, sleep deprived
ENERGY: Choose ONLY ONE answer that best describes you.
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have great energy through the day and evening
generally have pretty good energy, could have more
good energy except afternoons, after lunch
energy goes up and down, tends to be low
low energy, fatigue, need stimulants (coffee, tea, etc.)
IMMUNITY: Choose ONLY ONE answer that best describes you.
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excellent immunity, rarely sick, get well quickly
occasionally sick but get well soon
get sick when stressed or run down
tend to catch anything that comes around
often sick, hard to get well, long recovery time
MIND - EMOTIONS: Choose ONLY ONE answer that best describes you.
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no mental or emotional complaints
mind OK but not what it was, some moodiness
some focus issues, sometimes anxious or depressed
bad memory, forgetful, and/or up and down moods
"brain fog" or anxious or depressed often
SMOKING: If you currently smoke tobacco or have smoked tobacco in the past one to two years check Yes.
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Yes
No
ALCOHOL: If you currently drink any alcohol regardless how much or how little check Yes.
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Yes
No
RECREATIONAL DRUGS: If you currently use recreational drugs regardless of type or frequency check Yes.
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Yes
No
MOTIVATION: Rate your MOTIVATION to follow a health-building program on a scale from 1-10, with 1 being the lowest level of willingness and 10 being the highest level.
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Please enter a number from 1 to 10.
WILLINGNESS: Rate your WILLINGNESS to follow a health-building program on a scale from 1-10, with 1 being the lowest level of willingness and 10 being the highest level.
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Please enter a number from 1 to 10.
Full Name
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Email
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