First Name:
Last Name:
Street Address 1:
Street Address 2:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Fax Number (opt.):
Email Address:

Male/Female:	Female Male	Age:
Height [inch]:		Weight [lb]:
Is There A History of Allergies in your Family? Yes/No:			Yes No
What are your main complaints (In Order of Importance):			Duration of Problem:

1.
2.
3.
4.
5.
6.

List All Medications (Prescription & OTC) Currently Taken on Regural or as Needed Basis:
DRUG	DOSAGE	#TIMES/DAY	START DATE

SCALE OF SYMPTOMS SUFFERED DURING THE LAST SIX (6) MONTHS
Select option 0	If You Do Not Suffer From This AT ALL (default value)
Select option 1	If You Suffer Occasionally (less than twice a week) and it is Not Severe
Select option 2	If You Suffer Frequently (2 or more times per week) and It Is Not Severe
Select option 3	If You Suffer Occasionally (less than twice a week) and When You Do It Is Severe
Select option 4	If You Suffer Frequently (2 or more times per week) and When You Do It Is Severe
EXAMPLE   0    1     2    3    4 select value associated effect

Click here to show the SCALE OF SYMPTOMS as reference in a seperate window.

CONSTITUTIONAL SYMPTOMS

0    1    2   3    4
	Fatigue (tired, sluggish)
	Hyperactive (nervous energy)
	Restless (can't relax/sit still)
	Sleepiness during day
	Insomnia at night
	Malaise (feel lousy)

LUNGS

0    1    2   3    4
	"Wheezing" (Asthma/ Asthma-Like Symptoms)
	Chest Congestion
	"Non-Productive" Coughing
	"Productive" Coughing

EMOTIONAL/MENTAL SYMPTOMS

0    1    2   3    4
	Depression (feelings of hopelessness)
	Anxiety (vague fears, uneasiness)
	Mood Swings (rapid, distinct changes)
	Irritability (anger, hostility)
	Forgetfulness
	Lack of Concentration/Focus

EYES

0    1    2   3    4
	Red or Swollen Eyes
	Watery Eyes
	Itchy Eyes
	"Dark Circles" or "Baggy"

GENITOURINARY

0    1    2   3    4
	Increased Urinary Frequency
	Painful Urination

HEAD/EARS

0    1    2   3    4
	Headache (any kind)
	Earache
	Ear Infection
	Ringing in Ear
	Itchy Ears
	Discharge from Ear

MUSCULOSKELETAL

0    1    2   3    4
	Joint Pains/Aching
	Stiff Joints
	Muscle Aches
	Stiff Muscles
	Arthritis (Diagnosed)

SKIN

0    1    2   3    4
	Blemishes, Acne
	Rashes, Hives
	Eczema
	"Rosy" Cheeks

CARDIOVASCULAR

0    1    2   3    4
	Irregular Heartbeat
	High Blood Pressure (Diagnosed)

NASAL/SINUS

0    1    2   3    4
	Post Nasal Drip
	Sinus Pain
	Runny Nose
	Stuffy Nose
	Sneezing

DIGESTIVE

0    1    2   3    4
	Heartburn/Esoph. Reflux
	Stomach Pains/Cramps
	Intestinal Pains/Cramps
	Constipation
	Diarrhea
	Bloating Sensation
	Gas (of Any Kind)
	Nausea, Vomiting
	Painful Elimination

MOUTH/THROAT

0    1    2   3    4
	Sore Throat
	Swollen Throat
	Swelling of Lips/Tongue
	Gagging or Throat "Clearing"
	Lesions ("Canker Sores")

WEIGHT MANAGEMENT

0    1    2   3    4
	Overweight
	Fluctuating Weight
	Food Cravings
	Water Retention
	Binge Eating or Drinking
	Purging (all methods)