Holistic HealthQuestionnaire - Part 1Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *AgeHeight (inches)Weight (lbs)Amount Over or Under WeightBlood Pressure (without medication)Resting PulseReason for Seeking a Consultation *Do You Feel You Are Basically Healthy?Choice 5YESNOSometimesWhat are your Primary Health Concerns? *EmploymentChoice 4EmployedSelf EmployedRetiredCurrent OccupationPrevious OccupationMarital StatusChoice 6SingleSignificant OtherMarriedWidowWidowerDo You Live With?ParentsSpouse/PartnerRoommatesFriendsAloneDo You Smoke?TobaccoMarijuanaVapeOtherIf OtherList other substance that is smoked.If Stopped, How Long Since You Quit?Do You Use Caffeine?CoffeeTeaCarbonated BeveragesNo, I do not use caffeinated beveragesIf Stopped, How Long Since You Quit?Do You Now, or Have You Ever Used Recreational Drugs?Choice 3YesNoIf Stopped, How Long Since You Quit?Submit