Health History Form

Please complete this Health History Form to the best of your ability and submit by clicking the submit button below. Thank you!

* Indicates required field

Name *

First

Last

Email *

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.