Phone Number
Email *
1. What is your chief complaint? *
2. How long has this been happening? *
3. How satisfied are you with your digestion? *
4. How satisfied are you with your weight? *
5. Do you ever have gas? How frequently, and what part of the day? *
6. Have you ever taken antibiotics? Which ones, how long, and when: *
7. Please describe your morning routine: *
8. Please describe your diet: *
9. Please list all supplements you are taking: *
10. Please list the ones that have helped, and for what: *
11. Please list any and all medications you have taken in your entire life: *
12. Please list any conventional medications you are currently taking: *
13. Please list any medical diagnosis: *
14. Please describe what types of doctors you are currently seeing: *
15. How often do you have appointments with them? *
16. How have they been able to help you? *
17. Do you have access to testing your bloodwork? *
18. What is your occupation? *
19. How many hours a week do you work? *
20. Do you like your job? *
21. Please describe any trauma that may have taken place in your life: *
22. Please describe your family life: *
23. Is there anyone in your life that you need to forgive? *
24. Describe your level of fear on a daily basis from 1-10. *
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