Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Time of Birth Place of Birth* Home Phone*Cell PhoneEmail* Number of organs removed(e.g. tonsils, appendix, etc. - count ovaries individually)Number of prescription or over the counter medications taken dailyNumber of times a day you smoke or chew tobaccoNumber of steroid type drugs taken in the past year, include inhalersNumber of silver amalgam type dental fillings in current teethNumber of street drugs used each monthNumber of known allergiesNumber of persistent thoughts by category e.g.; work, relationship, health issues, etc.On a scale of 1-100% how much do you feel it is your responsibility for your health*Amount of fat in your diet by % (average American diet is at 40%)Rate overall stress level (1–10 with 10 highest)Please enter a number from 1 to 10.Number. of times a week you exercise 20 minutes or moreNumber of alcoholic drinks consumed daily, or average out for weekNumber of caffeine products consumed daily e.g.; coffee, tea, Red Bull, etc.Number of toxic exposures e.g.; CT scan, chemotherapy, radiation therapy, etc.Number of past injuries emotional & physical – include surgeriesNumber of past major infections that required hospitalization or long term medicationNumber of glasses of pure water you drink on average per dayDo you feel you are overweight? If so, by how much? Do you wear a pacemaker?* Yes No Are you pregnant? Yes No Have you ever had electro-shock therapy? Yes No Signature of client - (parent for minor)*Entering you name below functions as a "digital signature". PhoneThis field is for validation purposes and should be left unchanged. Δ