Below is the Questionnaire that will need to be completed. Please send me an e-mail at Support@RegenerateNaturallyNow.com and I will send you this form as well as the two others to be completed and emailed back to me...
Last Name________________________ FirstName_____________________________
Middle Initial ___________________ Date of Birth_________________________
Age______________ Sex_____________ Nickname____________________
Present Health Concerns:
Please list your health concerns in order of priority,including starting date and severity of symptoms.
1. ________________________________________________________________
2._________________________________________________________________
3._________________________________________________________________
4._________________________________________________________________
5._________________________________________________________________
6._________________________________________________________________
What do you believe is causing your most important health concerns ?
__________________________________________________________________
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What goals do you have for your Online or Office Visit Today ?
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Medications: Please list any prescription drugs,over-the-counter medications and
supplements (vitamins,minerals,nutrients,herbs,homeopathic remedies,etc.) you
are currently taking ?
Medication / Supplement--- Reason--- Date Began--- Dose
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Allergies: Please list and describe any severe or life-threatening allergies
(medications,stings,food,etc.):
Past Medical History: Please list the date of or age at each event and describe:
Serious Illnesses and Injuries:__________________________________________
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Hospitalizations:_____________________________________________________
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Date of last physical / annual exam:_____________________________________
Date of last blood test:________________________________________________
Childhood Illnesses: (Please check all that apply).Your health as a child was:
__________Good ______________ Fair _____________ Poor
____ Chicken Pox ______ Mononucleosis (Mono) ______Rheumatic Fever
____ Diptheria _______ Mumps _______Tonsilitis
____Ear Infections _____ Pertussis (whooping cough) _____ Scarlet Fever
___German Measles (Rubella) ______Pneumonia _____Strep Throat (Recurrent)
______ Measles _______ Polio
Personal and Family Medical History:
Please check the box next to each condition that applies to (you) or (one) of your
biological family members:
You - Mom - Dad - Sibilings -GrandParents
Current Age or Age at Death___________________________________________
Alcohol / Drug Abuse_________________________________________________
Allergies or Hay Fever________________________________________________
Alzheimer's or Dementia______________________________________________
Anemia____________________________________________________________
Anxiety / Panic Attacks_______________________________________________
Arthritis / Joint Disease________________________________________________
Asthma_____________________________________________________________
Autoimmune Disease_________________________________________________
Bleeding Disorder____________________________________________________
Cancer (What Type ?)_________________________________________________
Celiac Disease______________________________________________________
Chrons Dis / Ulcerative Colitis__________________________________________
COPD / Emphysema_________________________________________________
Depression / Suicide Attempt__________________________________________
Diabetes____________________________________________________________
Eczema____________________________________________________________
Epilepsy or Seizures_________________________________________________
Glaucoma__________________________________________________________
Gall Bladder Disease_________________________________________________
Migraines / Headaches_______________________________________________
Heart Attack________________________________________________________
Heart Disease_______________________________________________________
High Blood Pressure__________________________________________________
High Cholesterol_____________________________________________________
HIV / AIDS__________________________________________________________
Kidney Disease______________________________________________________
Liver Disease / Hepatitis_______________________________________________
Osteoporosis________________________________________________________
Schizoprenia_________________________________________________________
Stroke_____________________________________________________________
Thyroid disorder______________________________________________________
Other:______________________________________________________________
Review Of Systems: Check (_______) symptoms that you currently experience.
Constutional Heart & Circulation Digestion & Intestine
Max weight ___Heart Murmur ___Bad Breath
___Irregular Heartbeat ___Excessive Thrist
_____LbsYear______ ___Chest Pain ___Difficulty Swallowing
___Heart Palpitations ___Indigestion
___Appetite Change ___Light Headed ____Belching
___Weight Change ___Fainting ____HeartBurn / Reflux
___Fevers or Chills ___Blood Clots ____Nausea
___Sweats ___Deep Leg Pain On Walking ____Vomiting
___Feel Hot or Cold ___Varicose Veins ____ Abdominal Pain
___Fatigue ___Swelling Of Feet / Ankles Or Cramping
___Weakness ___Cold Hands / Feet ____Gas Or Bloating
___Anemia ____# Of Bowel Movements Per Day
( Eyes ) ___Easy Bruising ____Constipation
___Eye Pain ___Bleeding Tendency ___Loose Stool Or Diarrhea
___Poor Night Vision ___Blood Transfusions ____Mucus in Stool
___Glasses or Contacts (Chest & Lungs) ____Blood in Stool
___Near or Far Sighted ___Shortness Of Breath ____Rectal Pain Itching
___Blurred or Double Vision At Rest -Walking-Lying Down _____Heorrhoids
___Cataracts ___Wheezing Or Asthma ______Hernia
___Dry Eyes ___Cough:Wet Or Dry ______Jaundice
___ Brest Lump Or Pain (Muscles,Bones & Joints)
(Ears,Nose,Mouth,Throat) ___Nipple Discharge ____Neck Pain
___Self Breast Exams ____Back Pain
___Ringing in Ears (Neurological) ____Muscle Pain
___Earaches ___Dizziness ____Joint Pain
___Itchy Ears ___Poor Balance (Indicate R Or L)
___Wrist ___Fingers
___Excessive Ear Wax ___Poor Coordination ___Elbow ___Shoulder
___Hearing Loss or Hearing Aid ___Tremors Or Shaking ___Hip ____Knee
___Nosebleeds ____Seizures ___Ankle ___Foot
___Stuffy or Runny Nose ____Headaches _____Joint Swelling
___PostNasal Drip ____Migraines ___Morning Sickness___Hours
___Sinus Problems ___Numbness Or Tingling __Joint Replacements
___Change in Taste or Smell ____Nerve Pain ______Muscle Weakness
___Teeth / Gum Problems ____Memory Loss ______Muscle Cramps
___Grinding Teeth ____Poor Concentration (Skin,Hair,Nails)
___Dentures ____Changes in Speech ____Acne
___Mouth Sores (Mental / Emotional) ____Rashes
___Dry Mouth ____Mood Swings ____Itching Or Hives
___Sore Throat ____Anger,Frustration,irritability ___Dry Skin Or Eczema
___Hoarseness ____Sadness Or Anxiety ____Moles Or Growths
___Jaw Clicking or Pain ____Phobias ____Poor Wound Healing
___Facial Pain ____Insomnia Or Disrupted Sleep ____Hair Loss
____Nail Problems
(Immune System) ____Other:
(Women Reproductive)
___Frequent Infections ____Age Period Started ____Sores On Genitals
___Allergies to Foods ___Last Pap Smear ____Last Mammogram
___Enviornmental ____# Pregnancies ____#Live Births___#Miscarriges
___Lymph Gland Swelling / Pain ____Menopausal Symptoms____Infertility
___Other: ____Heavy Periods ____Hormone Replacement
(Men Reproductive) ____Abnormal Pap Smear ____Vaginal Discharge
____Sores On Genitals ____Prostate Problems
____Discharge ____Sexual Difficulties
____Testicle Lump / Swelling / Pain
( Social History )
Marital Status:___Single___Married___Divorced___Widowed
___Significant Other
Do you have any children ? ___Yes ___No
Please list their ages:_____________________________________
Household:___Alone___Roommate(s)___Spouse / Significant Other
___children___Grandchildren___Parent
Education Level:___High School___College___Professional School
___Other:____
Occupation:___Student___Work___Homemaker___Unemployed
___Volunteer___Retired
School / Occupation(s):___________________Hours per week:____________
Do you find your life:___Unsatisfactory___Too demanding___Boring
___Satisfactory___Wonderful
Lifestyle and Personal Habits:
What are your primary sources of stress ? ___________________________________________________________________
___________________________________________________________________
How much does stress impact your life ? ______________________________
___________________________________________________________________
Hours of play / relaxation per week ? _________________________________
How do you manage stress and take care of yourself ?__________________
___________________________________________________________________
Are you:
Currently sexually active ? ___Yes ___No Partners: #___Male___Female
Contraception;___Yes ___No
Satisfied with your sex life ? ___Yes ___No If no, why_______________
_________________________________________________________________
Satisfied with your social life? ___Yes ___No If no, why ? _________________________________________________________________
Satisfied with your Spiritual life ? ___Yes ___No If no, why? _________________________________________________________________
Do you:
Enjoy your Job ? ___Yes ___No If not, why ? _______________________
_________________________________________________________________
Exercise regulary ? ___Yes ___No If no, why ? __________________________________________________________________
Which exercises ? ___________________________________________________________________
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Sleep soundly and wake rested ? ___Yes ____No If no,why ? ___________________________________________________________________
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Smoke Cigarettes ? ___Yes ___No ___Quit___How many years ? ______
How many packs per day ? __________________________________________________________________
Drink Alcohol ? ___Yes ___No ___Quit___Type ?___ Drinks per week ?___________________________________________________________________
Use recreational drugs ? ___Yes ___No ___Quit ___Which___How Often ? _________________________________________________________________
Drink caffeinated beverages ? ___Yes ___No Type?____Drinks per day?__________________________________________________________________
Diet: Please describe your typical meals.
Breakfast Lunch Dinner Snacks
Time______ Time______ Time______ Time______
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Do you have any dietary restrictions ?___________________________________________________________________
How often do you eat out ?___________________________________________________________________
What are your food cravings ?___________________________________________________________________
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Water:_____ oz. per day Other beverages_____________________
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What else would you like us to know about you ? ________________________________________________________________
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Signature of Client Signature of Nutritional Conultant
__________________________ ________________________________
Date Date
