Health History Form The better our communication, the more momentum we create toward solutions. Tell your story! The more detail, the better.Consider your health over your entire lifetime. Email Lab Test Results Here Submit Your Health History FORM Please enable JavaScript in your browser to complete this form.Your Name *FirstLastPlease describe your more recent Health History.EXAMPLE: "I was diagnosed with asthma at age 11..."Please describe your recent Symptoms.EXAMPLE: "I've been having trouble falling asleep lately..."Please describe your recent Diet & whether it's helping.EXAMPLE: "I've been limiting eggs for the last week.."Please describe your Digestion, recently.EXAMPLE: "My digestion is improving, but I feel like I'm not as regular as I should be..."Please describe your recent Sleep quality.EXAMPLE: "My sleep seems to have changed the last week or so..."Please describe your recent Supplement habits, noting supplements that have been working and not working.EXAMPLE: "I've been trying the B-Complex for 3 weeks now, and it seems to be..."How do you feel about your current Home and Work Environments?EXAMPLE: "No change here, but I'm wondering if I should buy an air purifier..."Describe your current (or recent) Prescription Drugs:EXAMPLE: "I've been prescribed __________ for the last two years..."Do you have any Food, Medication, or Environmental allergies?EXAMPLE: "I developed an egg allergy 2 years ago..."Is there anything else you'd like for me to know? Any questions you'd like to ask me?Email *Phone Number, Video (Skype, Zoom) Contact InfoThis is how we'll communicate during our consultation.WebsiteSubmit Info