Health History Form | Travis Burch

The more information we work with, the more likely we are to uncover issues and find solutions.

Your Name *

First

Last

Please 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 Info

This is how we'll communicate during our consultation.

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