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Please create and enter a unique 8-12 character long ID code. This is used instead of a name to ensure that your medical information is anonymous and protected. Make sure to record it so you can relay it to me later.
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What is your current age?
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Click all of the conditions that apply to you:
Autoimmune Disease
Depression
Chronic Fatigue Syndrome
Hypothyroidism
Hashimoto's Thyroiditis
Anxiety
Weight Gain
Diabetes (Type 1)
Diabetes (Type 2)
Pre-Diabetes
Hypertension
Asthma
High Cholesterol
Chronic Pain
Insomnia - Mild to Moderate
Insomnia - SEVERE
Rheumatoid Arthritis
'Regular' Arthritis (AKA 'Osteoarthritis')
Fatty Liver
Cancer
Frequent UTIs
Migraines
ADD / ADHD
Poor Memory or Focus
Eczema
Acne
Celiac
Crohn's
Ulcerative Colitis
Diverticulitis
Bipolar
Schizophrenia
PMS
Seasonal Allergies
Frequent Sinus Infections
Chronic diarrhea
NONE OF THESE APPLY
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List your top 3 health concerns, starting with the most important
(In other words, the top 3 health priorities you'd like us to focus on)
Please list any medical conditions that were not on the previous list:
SKIP if you do not have any more conditions to list
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On average, how would you rate your stress level on a scale of 1 to 10 within the last month?
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On average, how would you rate your energy level on a scale of 1 to 10 within the last month?
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On average, how would you rate your focus & memory on a scale of 1 to 10 within the last month?
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How often do you exercise?
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Do you typically wake up feeling rested and refreshed?
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How often do you wake up in the middle of the night?
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What are your stress relief and mental wellbeing practices?
[This can be anything, from meditation, to yoga, to church, to connecting with family, to walking in nature. Write 'NONE' if you don't have any.]
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Do you regularly have any of the following digestive symptoms?
[Please mark ALL that apply]
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Do you subscribe to any particular kind of diet?
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Do you smoke cigarettes?
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How frequently do you drink alcohol?
Please list any foods you are allergic to or believe you are sensitive to:
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What did you last eat for breakfast?
[If you never eat breakfast, just say "don't eat breakfast"]
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What did you last eat for lunch?
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What did you last eat for dinner?
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List your 5 favorite snacks
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How much soda do you drink per day?
[Not including sparkling water]
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Have you ever taken the antibiotics Cipro or Levaquin?
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Please list all medications you take along with doses (including over the counter)
[Write 'NONE' if you don't take any]
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Have you suffered any major emotional traumas in the last 2 years?
Please list any major surgeries you have had
[SKIP if you have not had any]
Please list any abnormal lab findings you have had in the last year
[If you can't find them right now, that's okay. Try to have them handy during your session if possible. SKIP if you have not had any abnormal labs.]
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Would you describe yourself as
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How often do you eat out?
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Have you felt any of these emotions on a regular basis in the last few months?
[Mark all that apply]
Do you have adverse reactions to any of the following items?
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How many mercury ["silver"] fillings do you have?
Have you lived with a house with mold at any point in the past? When was it?
[SKIP if not]
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On a scale of 1 to 5, how ready are you to change your diet to improve your health?
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On a scale of 1 to 5, how ready are you to take supplements to improve your health?
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On a scale of 1 to 5, how ready are you to modify your lifestyle to improve your health?
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On a scale of 1 to 5, how ready are you to exercise to improve your health?
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On a scale of 1 to 5, how ready are you practice stress reduction techniques to improve your health?
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Last one, you made it! Please remember to email pictures of all of your supplements as soon as you can to drmatt@drmattdorsey.com
