Holistic HealthQuestionnaire - Part 2Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Nourishment As A Baby: *Choice 5Breast FedBreast Fed & Formula FedFormula Fed Only (Bottle)If Breast Fed, How Long? *Age Introduced to Solid Food: *Age Introduced to Dairy? (cow milk products) *Age Introduced Wheat Products? *Did You Eat a lot of Candy or Sugar as a Child? *Choice 5YESNOSometimesSeldomPlease List Any Known Allergies as a Child? *Serious Illness as a Child: *Rheumatic FeverProlonged FeverKidney TroubleHeart TroubleAsthmaPneumoniaOtherNo Known Illness as a ChildCheck any that applyIf Other, Please Specify: *Please detail any known Child IllnessHave You Had, or Do You Have Any of the Following? *Fever, chills, night sweatsSevere or frequent headachesPeriods of unconsciousnessComplete or partial blindnessFrequent dizzy spellsHearing troubleEye troubleI feel anxious, depressed, or irritableTrouble dealing with stressHay fever or sinus troubleGoiter or thyroid troubleAsthmaCoughCoughed up bloodMucous I chest or bronchial areaShortness of breathHigh blood pressureHeart troubleI have had jaundice, hepatitis, or monoAwaken at night out of breathFast, irregular, or slow pulsePain in chestAllergiesVaricose veinsFrequent colds or fluVomit bloodRecent change in bowel habitsBlack bowel movementsFresh blood in bowel movementsDiarrheaConstipationAlternating diarrhea and constipationFrequent indigestion or gasUlcer of stomachBurning when you urinateBlood in urineNeed to urinate frequentlyUrinate often during the nightKidney or bladder stonesProtein or albumin in urineTrouble starting urine streamSwollen lymph glandsUrinary infectionVenereal disease or HerpesDiabetes or sugar in urineHypoglycemia (low blood sugar)Arthritis, BursitisRheumatismNervous breakdownSkin rashesI do not have a good appetiteExercise at least three times per weekSleep wellI do not sleep wellI do not feel rested in the morningI feel tired after eatingTired or diminished energy during the dayCheck any that applyPlease Describe Reoccurring Conditions Selected *Describe conditions of concernWhat Items Below Are You Currently Taking: *MedicationsVitaminsSupplementsHerbsEssential OilsOtherSelect all that applyIf Other, Please Specify:List Dose and Frequency of Current Medications:List Dose and Frequency of Past Medications:List Dose and Frequency of Current Vitamins, Supplements, Herbs, and Essential Oils:Diagnosed or Known Allergies to: *MedicationsChemicalsEnvironmental (plants/trees)FoodsHerbsEssential OilsOtherSelect all that applyProvide Details about Allergies Selected Above:Operations/Injuries, Including Dates:Have You Ever Been in the Hospital for Other Reasons? *Please indicate when and whyHas Your Weight Changed in the Last Year?Choice 3YESNOIf Yes, How Much?Current Weight?Weight 1 Year Ago:ApproximantlyWeight 5 Years Ago:ApproximantlyWhat is the Primary Goal You Hope to Achieve Through the Health Consultation Process. *Please Use This Space to Write in Any Other Important health Consideration You May Have. The More Specific, Yet descriptive, Your Information is, the More We Will Be Able to Help You. *Submit