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Your Health

Please provide an overview of the current state of your health.

What type of illness or health issue(s) are you experiencing?

If you have cancer, there is it located (in the case of metastasis, please indicate primary cancer)

Are you currently receiving chemotherapy or radiation?

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If you have received chemotherapy or radiation, has at least 1 month passed?

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When was your illness diagnosed?

Have you had any surgery relating to this problem?

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Please tell us about any relevant medical history and/or other treatments and therapies you have done (e.g. illness, hospitalization, yoga, meditation, colonic irrigation, IV treatment etc)

Are you experiencing any of the following (please check all that apply)?

Allergies or IntolerancesPainAscites or Edema (fluid retention)Hearing ProblemsDizzinessVertigoTinnitusHeadachesNeck/Shoulder/Back Pain or TensionExcessive Weight LossInsomniaNightmaresUrinate more than twice a nightCold FeetI struggle with nasal breathingI snore

High Blood PressureLow Blood PressureIndigestion / Bloating / HeartburnUrinary InfectionsConstipationHaemorrhoidsShort-TemperednessIrritabilityNervousnessAnxietyDepression or other Mental IllnessProblems eating or swallowingConfined to wheelchair or bedTrouble climbing one flight of stairsMy job requires a lot of standingMy job requires a lot of sitting

In the last 5 years, have you experienced any emotional shock?

If you suffer pain, where is it located?

On a scale of 1 to 10, how bad is the pain (1 being mild, 10 being severe)

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If you suffer ascites or edema (fluid retention), where is it located?

How many root canals do you have?

How many teeth extractions have you had?

12345678910More than 10

Please list all pharmaceutical medicine you are currently using

Is there anything else you would like to add that you think we should be aware of?

At what times are you available for us to reach you?

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Your Health

On a scale of 1 to 10, how bad is the pain (1 being mild, 10 being severe)

Your Declaration

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