Date of Birth:
Names and Ages:
Other Significant Relationships:
Current Living Situation:
Daily Schedule/Activities (include work/profession):
Daily Physical Exercise/Movement:
How much water do you drink?
Is it tap water? Source?
What else do you drink?
Health/Medical History (diagnosis, surgeries, illnesses, etc):
Dental Issues (fillings, root canals, bridges):
Family Health/Medical History (diagnosis, surgeries, illnesses, etc):
Family/Personal Relationship History:
Where did you grow up?
Medications, Supplements, Vitamins, Herbs, Homeopathics, etc.:
Previous Treatments Attempted:
Description of daily activities that affect body, mind, spirit:
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