All-Day Energy Blueprint (Group Cohort ) Full Health Intake

Please complete my full health intake form to your comfort level before enrolling in the All-Day Energy Blueprint Program. Your background health history and any medications you are currently taking are important for me to know in order to customize any aspect of my program to fit your needs.

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Question 1 of 53

First and Last Name

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Question 2 of 53

Email Address

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Question 3 of 53

Full Mailing Address

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Question 4 of 53

Phone Number

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Question 5 of 53

Age

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Question 6 of 53

Height and Weight

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Question 7 of 53

Occupation

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Question 8 of 53

Today's Date

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Question 9 of 53

Describe Problem(s):

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Question 10 of 53

When exactly did it/they start?

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Question 11 of 53

What treatments have you tried?

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Question 12 of 53

Has anything been successful?

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Question 13 of 53

Do you have any pets or farm animals? If yes, where do they live?

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Question 14 of 53

Have you lived or traveled outside of the United States? If so, when and where?

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Question 15 of 53

Have you or your family experienced any major life changes or losses, either recently or in the past? If yes, please comment:

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Question 16 of 53

How much time have you lost from work or school in the past year?

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Question 17 of 53

Have you been involved in abusive relationships in your life?

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Question 18 of 53

Did you feel safe growing up?

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Question 19 of 53

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?

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Question 20 of 53

Do you feel safe, respected and valued in your current relationship?

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Question 21 of 53

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

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Question 22 of 53

How often have you taken antibiotics?

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Question 23 of 53

List past Medical and Surgical History:

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Question 24 of 53

How often have you have taken oral steroids?

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Question 25 of 53

What medications are you taking now?

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Question 26 of 53

List all vitamins, minerals, and other nutritional supplements that you are taking now.

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Question 27 of 53

Were you a full-term baby? A preemie? Breast fed or bottle-fed?

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Question 28 of 53

As a child did you eat a lot of sugar and/or candy?

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Question 29 of 53

What is your typical daily diet:

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Question 30 of 53

Which of following do you consume each week?

(Select all that apply)

A

Tea

B

Coffee

C

Soda

D

Other Caffeine

E

Dairy/Cheese

F

Bread

G

Sugar

H

Candy/Chocolate

I

Dessert

J

Alcohol

Question 31 of 53

Are you on a special diet? Is there anything I should know about your diet?

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Question 32 of 53

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any food or supplement(s)?

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Question 33 of 53

Do you feel much worse when you eat certain foods?

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Question 34 of 53

Do you feel much better when you eat certain foods?

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Question 35 of 53

Does skipping a meal greatly affect your symptoms?

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Question 36 of 53

How many bowel movements do you have per day?

A

0-1

B

1-2

C

2-3

D

3+

E

maybe a few per week

Question 37 of 53

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?

A

Constipation

B

Diarrhea

C

Neither

Question 38 of 53

Do you have intestinal gas? If so, when? (e.g., after eating, upon waking, etc.)

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Question 39 of 53

How many times per week do you drink alcohol?

A

Never

B

<2 drinks per week

C

2-4 drinks per week

D

4+ drinks per week

Question 40 of 53

Have you ever used recreational drugs?

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Question 41 of 53

Have you ever used tobacco? (If so, for how long?)

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Question 42 of 53

Are you exposed to second-hand smoke regularly?

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Question 43 of 53

Do you have mercury amalgam fillings in your teeth? If so, how many?

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Question 44 of 53

Do you have any artificial joints or implants? If so, which ones.

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Question 45 of 53

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

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Question 46 of 53

Do odors affect you? If so, which ones?

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Question 47 of 53

How would you rate your current level of stress on a scale of 1-10, with 10 being the worst?

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Question 48 of 53

Have you ever had

psychotherapy or counseling?

A

Yes

B

No

Question 49 of 53

Are you currently, or have you ever been, married?

A

Currently married

B

Previously Married

C

Never Married

Question 50 of 53

List your hobbies and leisure activities:

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Question 51 of 53

Do you exercise regularly? If so, how many times a week and what type?

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Question 52 of 53

How many hours of sleep do you get per night on average?

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Question 53 of 53

Do your parents or siblings have (or had) any health issues? If so, please explain:

Paragraph answer

Confirm and Submit

Name

Email

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All-Day Energy Blueprint (Group Cohort ) Full Health Intake

Click the button below to start.

First and Last Name

Email Address

Full Mailing Address

Phone Number

Age

Height and Weight

Occupation

Today's Date

Describe Problem(s):

When exactly did it/they start?

What treatments have you tried?

Has anything been successful?

Do you have any pets or farm animals? If yes, where do they live?

Have you lived or traveled outside of the United States? If so, when and where?

Have you or your family experienced any major life changes or losses, either recently or in the past? If yes, please comment:

How much time have you lost from work or school in the past year?

Have you been involved in abusive relationships in your life?

Did you feel safe growing up?

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?

Do you feel safe, respected and valued in your current relationship?

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

How often have you taken antibiotics?

List past Medical and Surgical History:

How often have you have taken oral steroids?

What medications are you taking now?

List all vitamins, minerals, and other nutritional supplements that you are taking now.

Were you a full-term baby? A preemie? Breast fed or bottle-fed?

As a child did you eat a lot of sugar and/or candy?

What is your typical daily diet:

Which of following do you consume each week?

Are you on a special diet? Is there anything I should know about your diet?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any food or supplement(s)?

Do you feel much worse when you eat certain foods?

Do you feel much better when you eat certain foods?

Does skipping a meal greatly affect your symptoms?

How many bowel movements do you have per day?

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?

Do you have intestinal gas? If so, when? (e.g., after eating, upon waking, etc.)

How many times per week do you drink alcohol?

Have you ever used recreational drugs?

Have you ever used tobacco? (If so, for how long?)

Are you exposed to second-hand smoke regularly?

Do you have mercury amalgam fillings in your teeth? If so, how many?

Do you have any artificial joints or implants? If so, which ones.

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

Do odors affect you? If so, which ones?

How would you rate your current level of stress on a scale of 1-10, with 10 being the worst?

Have you ever had psychotherapy or counseling?

Are you currently, or have you ever been, married?

List your hobbies and leisure activities:

Do you exercise regularly? If so, how many times a week and what type?

How many hours of sleep do you get per night on average?

Do your parents or siblings have (or had) any health issues? If so, please explain:

Confirm and Submit

Have you ever had

psychotherapy or counseling?