Patient Assessment Form

Surname *

First name(s) *

Date of birth *

Gender

Height

Weight

Occupation

Marital status

No. of children

Full address

City

Postal / Zip code

Country

Phone (include international dialling code)

Phone (mobile)

Email *

Who referred you?

Your doctor(s)’ name, specialty, and contact details

Your dentist’s name and contact details

What are your current symptoms? *

How long have you been suffering from the above symptoms?

Does anything make your symptoms worse / better?

Has your condition been given a medical name / diagnosis? If so, what?

Please list any other conditions you suffer/have suffered from, e.g. asthma, high blood pressure, diabetes, epilepsy, childhood illnesses etc.

Please list any previous surgical operations, together with dates (include any accidents/fractures/trauma)

Have you ever had a blood transfusion? If so, when and why?

Does anyone else in your family or in your workplace suffer from the same symptoms/disease as you?

Do you eat large or regular amounts of chocolate and sweets?

Do you eat organic fruits and vegetables?

Are you happy with your eating habits?

Do you exercise? If so, what kind of exercise, and how often?

Are you happy where you live now? If not, why?

Have you always lived there? If not, briefly mention towns/cities/countries you have lived in the past (since childhood)

Is your occupation stressful? If so, why?

How is your relationship with your co-workers?

How is your relationship with friends and family? Any problems?

Are there any stressful circumstances in your life right now?

Are you traveling extensively?

Do you have any pets?

Do you have metal dental fillings? If so, how many?

Have you had any removed? If so, how many and when?

Did you follow a detoxification protocol with / after their removal? If so, what did it involve?

Do you have root canals? If so, how many?

Do you have crowns or other metals in your mouth? If so, what?

Do you use, or have you used, aluminum cookware?

Do you use, or have you used, spray deodorants or antiperspirants? If so, what kind?

Do you use, or have you used, hair colour dyes or bleaches? If so, what kind?

What cosmetics do you use regularly?

Do you use antacids?

Are you now or have you ever been on hormone replacement therapy (HRT)? If so, for how long?

Please list all your immunizations/vaccinations, together with dates

What kind of heating/air-conditioning do you have in your home?

What kind of heating/air-conditioning do you have at work?

Has there been any kind of remodeling/construction in your home recently?

Do you live or work near any farms, large agricultural areas, nuclear reactors or military bases? If so, what kind and how many miles away?

Have you ever been exposed to toxins of any kind? What?

Are there any high-tension lines or step-down transformers near your home or work?

Do you have any scars on any part of your body, and if so, where exactly?

Is there anything else you wish to add, which you think may be relevant?