Is this your first visit with christina santini?

Welcome - I am so happy to have you here!

Please fill this form out minimum 24 hr. before your scheduled appointment.

Please remember to email all labs you have had done within the last 12 months - if possible ask your primary doctor to have following labs done  (covered by insurance). Email all lab results before your appointment to info@christinasantini.com

Your first appointment is analysis of data and recommendations of further needed laboratory testing only. This, in order to develop your customized program and go over with you at your next appointment.

Name *
Name
What is your date of birth?
What is your date of birth?
Call your doctor's office if you don't know - they have it on file.
Who is your Medical Doctor?
Who is your Medical Doctor?
Who is your dentist?
Who is your dentist?
Check off any allergies you have
Check off vaccinations you have had
Check off any current and past diagnoses you have
Habits
Write down time, amount and what you ate and drank.
Check off food items you eat more than 1 x week
Please check off any of the following stimulants that you use > 1xweekly
Check off any diets you have ever tried
Hormone Health
Are you taking any of the following hormone therapies?
Please check off any of the following hormone types you are taking
Family Health
Social Health
Women's health
Please check off what applies to you
Men's health
Please check off what applies to you
Dental health
Check all that applies to you
Eye health
Check all that applies to you
Ear health
Check off all the applies to you
Heart health
Check off all that applies to you
Digestion health
Check off all that applies to you
Check off one answer for each number.
This section deals with your Ayurveda body type and used to customized recommendations further.