Health History Form

IMPORTANT: Please read:

Please complete this Health History Form to the best of your ability.
Complete it in one sitting; you can not save it and return to it later so gather all the data points you need such as medical records, journals, etc. before you begin.
If you accidentally send it before you finish it, please start a new one. Add your name and pick up where you left off on the form you sent. We will piece these together.
Please know I do not need your every detail about your traumas: I need the highlights described briefly.
Click the submit button to send. Thank you!

DO NOT CLICK ENTER UNTIL YOU ARE READY TO SUBMIT THE FORM

* Indicates required field

Email *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone *

Secondary Phone *

Birthdate *

Sex *

Referred by *

Current Weight *

Desired Weight *

Diagnosis of Primary Concern *

First Major Symptom of Primary Diagnosis *

Please describe all symptoms, including dates of changes *

Diagnosis of Secondary Concern (if any) *

First Major Symptom of Secondary Diagnosis *

Please describe all symptoms, including dates of changes *

Please list any additional diagnoses OR symptoms you want to address including the date they started *

List any accidents or operations including dates *

List dental issues and procedures including # of cavities, root canals, & crowns *

Bowel History including color, size, frequency, shape, & texture *

Please describe your typical diet for breakfast, lunch, dinner, snacks & beverages *

For how long have you had the diet described above? *

Please give an overview of pharmaceutical use over your lifetime. Include antibiotics, over the counter drugs, and prescription meds. *

On a scale of 1 -10 (low to high), what is the amount of stress in your life? *

List traumatic and/or shocking events in your lifetime with approximate dates *

What do you do for work? *

What do you do for pain? *

Please give an overview of supplements (vitamins, minerals, herbs, homeopathy, essential oils, etc) that you have taken regularly in the past 2 years *

What do you do for exercise and how frequent is it? *

Describe the quantity and frequency in which you use alcohol, recreational drugs, and tobacco *

List allergies *

List your health goals *

By clicking the SUBMIT button below, you are agreeing to the Disclaimer shown below. *

Submit

Disclaimer:

Please know that the information you receive in your consultation is not medical advice; instead, it is a sharing of knowledge and information from the education, research, training, and experience of Andi Locke Mears. This is not intended to replace the relationship with your primary health care providers.

You have the right to make your own health decisions based upon your research and in partnership with your primary health care providers, ND, MD or otherwise.

I, by clicking the submit button, reserve the right to seek or ask nutrition or wellness care advice, counsel, recommendations, suggestions, assessments, evaluations, test and/or treatments, regimens or modalities from the nutritionist or doctor or health care provider of my choice for any health reason or purpose.

I acknowledge that the information and service provided by Andi Locke Mears is not used to prescribe, recommend, diagnose, or treat a health problem or disease. It is not a substitute for medical care. I agree to hold Andi Locke Mears harmless from any present or future liability.

All Content found on andilockemears.com including: text, graphics, images, audio & video, was created for informational purposes only and do not constitute medical advice. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

In the event of a medical emergency, call a doctor or 911 immediately. Andilockmears.com and Andi Locke Mears, do not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by the website including from Andi Locke Mears and all Content is solely at your own risk. The Site and the Content are provided on an "as is" basis.