Health Checklist Name * First Name Last Name Email * Phone (###) ### #### GENERAL (Check All That Apply) Allergies Generally Cold Generally Hot Cold Hands/Feet Sweats Chills Weight Gain/Loss Low Energy Exercise Regularly Tremors Fainting Vertigo Feel Good Overall DISORDERS Thyroid Problems Adrenal/Endocrine Autoimmune Viral Problems Hepatitis Genetic Problems Neurological Problems Infertility Cancer Anemia Seizures Stroke EMOTIONAL Difficult Expression Anxiety/Worry Depression/Sadness Moodiness Forgetfulness Unclear/Foggy Mind Irritable/Impatient Over Stressed Compulsive Difficult Concentrating Unmotivated Frequent Crying Unrestrained Joy Generally Happy DIET & LIFESTYLE Food Allergies/Sensitivities Thirst Increase/Decrease Appetite Changes Vegetarian/Vegan Cravings Alcohol Use Tobacco Use SLEEP Difficulty Falling Asleep Wake Early of Often Insomnia Fatigued During the Day Frequent Dreams Lack of Dreams GASTROINTESTINAL Abdominal Pain Bloating Gas/Burping Acid Reflux/Indigestion Loose Stools Diarrhea Constipation Nausea Intestinal Disorders CARDIOVASCULAR High/Low Blood Pressure Chest Pressure or Pain Heart Palpitations Irregular Heartbeat Poor Circulation Swollen Ankles Varicose Veins Blood Clotting Disorders Heart Valve Abnormalities Broken Blood Vessels Additional Concerns Thank you!
