Full Name:

Date of Birth:

City/State/Zip:

Phone Number:

Age:

Gender:

Email:

Address:

1. What are your primary health concerns?

2. What specific outcomes are you hoping to achieve from this consultation?

3. Have you been diagnosed with any medical conditions? If yes, please specify:

4. Are you currently taking any medications or supplements? If yes, please list them:

5. Do you have any allergies? If yes, please specify:

6. Have you had any recent surgeries or hospitalizations? If yes, please provide details:

7. Do you exercise regularly? If yes, please describe your routine:

8. How would you describe your diet?

Do you smoke? Select Yes No

Do you drink alcohol? Select Yes No

Do you use recreational drugs? Select Yes No

10. How many hours of sleep do you typically get per night?

11. On a scale of 1-10, how would you rate your current stress level?

12. Do you experience anxiety, depression, or other emotional challenges?

If yes, please explain: