What is your main health complaint?
How long has this been bothering you?
Tell us about any other symptoms (please check all that apply)
Have you been diagnosed with any medical issues?
If yes, please give details
What medications are you taking?
What line of work are you in?
What time do you typically go to sleep?
What time do you typically wake up?
Do you find it easy to wake up?
How is your energy throughout the day?
Tell me about your eating habits
What do you usually have for breakfast?
What do you usually have for lunch?
What do you usually have for dinner?
What do you usually snack on?
What types of foods to you typically crave?
List any foods that make you feel bloated, gassy or heavy feeling:
List any foods that make you feel tired or gives you "brain fog" or a headache:
Digestion and Elimination
When is the best time to contact you?
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