Name
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First Name
Last Name
Email Address
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What is your address?
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your phone number, please?
Gender
Male
Female
What is your date of birth?
MM
DD
YYYY
What is your weight?
How tall are you?
Who is your Medical Doctor?
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First Name
Last Name
Who is your dentist?
First Name
Last Name
What is your current work?
How did you hear about the clinic?
Please rate your current life quality on a scale from 0-10 (10 is excellent, 0 is not-acceptable)
When did you start having a difficult time with food/ weight and why do you think it started?
Any other diagnosis/health concerns (mental + physical)?
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How long have you had the symptoms/diagnosis?
Which treatment options have you tried and what were the results of these?
What are your 3 major health concerns?
What are your expectations for this health check?
List any medications you are taking
List any supplements, herbs or homeopathic remedies you are taking
Are you following any specific diet currently - and if yes why?
Are you flexible with trying out other dietary recommendations if more suitable based on evaluation? If not, please explain why and describe any typical reactions you experience when changing your current diet.
Do you minimize your exposure to electrosmog from smartphones, wifi, ipads, fitbids?
No
Yes
Do you meditate/ do breathing exercises daily?
Check off any allergies you have
Check off vaccinations you have had
What is your ethnicity?
Caucasian
Middle-Eastern
Asian
African
Latino
Inuit
Check off any current and past diagnoses you have
What is your motivation to seek help with your relationship with food?
Do you have a set morning and evening routine (please describe)?
Morning and evening routines can help to normalize hunger patterns, metabolism, energy levels and improve hormone and sleep (melatonin).
How much are you exercising/ walking daily (hours)?
Do you use laxatives, purging, excessive exercise or other self-harm behaviours?
Please describe
What did you eat for the last 3 days?
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
Have you ever used any type of drugs incl. marijuana - if so, what types, how often and when?
Are you taking any of the following hormone therapies?
Please check off any of the following hormone types you are taking
Please list any disease and cause of death and age of mother, father, grandparents and siblings
Who are you currently living with?
Myself
Spouse
Parents
Friends
Family
What activities do you enjoy most in life?
What do you worry about most in life?
Please check off what applies to you
Please check off what applies to you
Check all that applies to you
Check off all that applies to you
How frequent do you have a bowel movement?
Check off all that applies to you
DISCLAIMER
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Your health program is designed as an adjuvant / supportive measure aimed at reducing bodily stress and strengthening the body. It does not replace medical treatment and does not intend to diagnose, cure or prevent disease.
We are not responsible for the effects, side effects and consequences of actions during and after the course. It is your responsibility and choice to maintain contact to your primary physician.
Thermography is utilized as an adjunctive imaging procedure only and, as such, is not a replacement for or alternative to any other form of imaging. Since thermography only detects heat at the surface of the body, the technology cannot see into the cranial vault, thoracic or pelvic cavities, or deep into the body to visualize organs or bones. All thermography reports are meant to identify thermal emissions that suggest potential risk markers only and do not in any way suggest a diagnosis or treatment. Since a diagnosis cannot be made from an infrared image, thermal markers must be correlated by the patient's treating physician with additional testing and procedures before a final diagnosis can be made.
By checking off below I agree to have read and accept the disclaimer.
I agree to have my health information shared with my other health providers
You will always receive notification prior to sharing any relevant health information with your other health practitioners.
I agree to have my results used anonymously for training and educational purposes.
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