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Bioenergetic New Patient Paperwork

First Name

Last Name

Date

Email address

Address

Date of Birth

What are your top 3 health concerns?

What are your top health goals?

Scale 1-10, how dedicated are you to improving your health?

List any Medical Diagnosis and Date of Onset

List Prior Surgeries or Hospitalizations.

List Current Supplements and Reason for Use.

List Current Medications and Reason for Use.

Have you taken antibiotics or steroids in the past? If Yes, Explain

Have you had reactions to supplements in the past? Explain

How much water do you drink, and what type? (Tap, Filtered, Bottled, etc)

Write out a typical days meal-(Breakfast, Lunch, Dinner, Snacks)

List any drinks you consume. (Coffee, Soda, Alcohol, etc)

List any foods you avoid and why.

Do you experience certain symptoms after meals? (Bloating, gas, pain, etc)

How many hours of sleep do you get in a typical night?

Do you have problems falling asleep?

Yes No

Do you have problems staying asleep?

Yes No

If yes, what time or times do you usually wake up at?

Do you wake frequently at night?

Yes No

Do you wake feeling rested?

Yes No

How often do you exercise? Type of exercise you do?

What are your main stressors?

What do you do to reduce stress?

What do you do to have fun?

How is your mental/emotional health? Is there anything I should know regarding this?

Do you have a history of tobacco use?

Yes No

Explain what dental work you have done in the past?

Metal fillings, Crowns, Root Canals, etc

Vaccinations in last 5 years? If yes, explain

Includes flu and covid

Any other information about skin and hair?

Any other information about Head, Eyes, Ears, Nose and Throat?

Cardiovascular Check any you have experienced in the last 6 months

High Blood Pressure

Poor Circulation

Fainting

Palpitations

Irregular Heartbeat

Low BP

Chest Pain

Dizziness upon standing

Any other information about cardiovascular?

Respiratory Check any you have experienced in the last 6 months

Cough

Bronchitis

Asthma

Shortness of breath

Production of phlegm

Pain on breathing

Difficulty breathing

Any other information about respiratory?

Urinary Check any you have experienced in the last 6 months

Painful urination

Incontinence

Kidney stones

Blood in urine

Decreased flow

Frequent urination

Urinary urgency

Irregular flow

Any other information about urinary?

How often do you have a bowel movement?

0-1 daily 1-2 daily 3-4 daily

Any other information about gastrointestinal?

Musculoskeletal Check any you have experienced in the last 6 months

Neck pain

Muscle pain

Back pain

Muscle weakness

Reduced range of motion

Joint stiffness

Fracture

Disc injury

Concussion

Any other information about musculoskeletal?

Reproductive-Female only* Check any you have experienced in the last 6 months

Heavy bleeding

Unusual bleeding

Discharges

Breast lumps

Pain with intercourse

Cramps

Irregular cycle

Clots

PMS? If yes, What are your symptoms?

Do you use birth control? If so, what type?

Length of your cycle? Have you gone through menopause, and if so, at what age?

Any other information about reproductive?

Anything else about neuropsychological?

General Check any you have experienced in the last 6 months

Fatigue

Slow metabolism

Excessive thirst

Chills

Night sweats

Fevers

Intolerance to heat/cold

Sudden energy drops

Anything else not listed in the symptom list that you would like to share?

*Kids Only*

Can your child swallow pills?

Yes No

How well does your child take supplements?

Describe your child's personality?

It's important to remember that healing is an inside job. We are here to guide you, educate you, support you, listen to you and care about you, but ultimately, it is YOUR job to heal you. If you choose not to do the protocol that bioenergetic testing provides, or make the necessary changes to support yourself, please know that the support I am able to provide will be limited. You will get out of it what you put into it. Please do not move forward unless you are ready to commit to the process.

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