FULL NAME: DATE: Date of Birth: / / (MM/DD/YYYY) Place of Birth: (City, State/Provence, Country) Email Address: Mailing Address: Billing Address: Phone Number(s) you are comfortable having our office call: Home - - Cell - - Work - - Top 3 Complaints: 1. 2. 3. Please provide a list of any/all medications (prescription and over the counter), supplements, etc below, or email a list to clientservices@ihsvt.com along with the frequency in which you take them.
How much do you weigh? lbs How tall are you? ft. in. Personal Stress Level (1=no stress, 10=stressed to the max!) How many organs have you had removed? Which organs & when Do you smoke? Yes No if Yes How many a day Do you have any Silver fillings? Yes No if Yes How many Known allergies (food, drugs, environment etc ) How many sugary products do you have in a day? (ie: ice cream, candy, cookies, etc ) Do you exercise? Yes No if Yes How often & duration Do you drink alcohol? Yes No if Yes How much & how often Do you drink coffee, tea, or soda? Yes No if Yes How much of each & how often In the last year have you had any of the following: X-Rays, MRI/CAT Scans? Yes No if Yes Which & how many In the last year have you had any exposures to the following: Chemicals, Insecticides? Yes No if Yes Which & how many Have you had any major injuries in the past? (ie: broken bones, car accident, etc ) Yes No if Yes What & when Have you had any major infections in the past? (ie: staff, strep, mersa, any repeated infection, etc ) Yes No if Yes What & when
How many glasses of water or juice to you drink each day? water juice Do you sleep well? Yes No Sometimes Do you have a hard time falling asleep? Yes No Sometimes Do you have a hard time staying asleep? Yes No Sometimes Do you feel rested in the morning? Yes No Sometimes Do you feel Tired? Yes No Sometimes Do you feel fatigued? Yes No Sometimes Do you have any headaches? Yes No Sometimes Are you irritable? Yes No Sometimes Have you ever experienced any depression? Yes No Sometimes if Yes Have you taken any medications for depression? Yes No Do you have Blood Pressure problems? Yes No if Yes Have you taken any medications for Blood Pressure? Yes No Do you have High Cholesterol? Yes No if Yes Have you taken any medications for High Cholesterol? Yes No
Do you have joint pain? Yes No Sometimes if Yes how painful (1-10) Do you have muscle pain? Yes No Sometimes if Yes how painful (1-10) Type of Pain: Dull Sharp How many bowel movements do you have a day? Do you have a history of Irritable Bowel Syndrome (IBS)? Yes No Do you have a history of Diverticulitis? Yes No Do you have a history of Chrone s? Yes No Do you have any of the following: Indegestion, Bloating, Gas, Belching, Reflux? Yes No if Yes Which & how often Have you been diagnosed with anything Dr. Debbie may find pertinent? if Yes
Have you been diagnosed with Cancer? Yes No if No you re finished with the questionnaire. Please submit it to clientservices@ihsvt.com if Yes Type Location Have you had any surgeries? Yes No if Yes What was removed & how many Do you have a history of any of the following: Black Fan, Falcone, Pernicious? if Yes Which Have you had a stem cell transplant? Yes No Are you on a transplant list? Yes No Do you have any dietary restrictions? Yes No Are you on a Ketogenic diet? Yes No Have you had any seizures? Yes No if Yes Are the seizures photogenic or tumor related? Did the seizures occur prior to cancer? Yes No