Genesis Life Wellness Center
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Do you have a family history of:
High blood pressure
High cholesterol
Heart attack
Stroke
Osteoporosis
Diabetes
Liver disease
Kidney disease
Gall bladder problems
Thyroid problems
Stomach problems
Digestive problems
Celiac disease
Anemia
Asthma
Allergies (hay fever)
Food allergies
Sinus problems
Tension headaches
Migraine headaches
Vertigo
Arthritis
Have you noticed some memory loss:
Yes
No
Sometimes
How often do you get a cold or flu per year?
Never
1x per year
2x per year
More that 2x per year
What lifestyle habits are you neglecting the most:
Healthy diet
Regular exercise
Drinking plenty of water
Enough rest
Stress management
Taking regular supplements
What's the primary health concern you would like to resolve:
Are there any issues that prevent you from exercising:
Describe your typical exercise routine:
How often do you exercise
Never
1-2 times per week
2-3 times per week
3-5 times per week
Daily
Do you get tired after meals
Yes
No
Sometimes
Do you get tired in the middle of the day?
Never
Sometimes
Frequently
Always
When you wake up in the morning are you:
Still exhausted
Somewhat still tired
Feel fine
Feel well rested
How many hours sleep do you get?
4-5 hours
5-6 hours
6-7 hours
7-8 hours
8+ hours
Do you take diet pills? (check all that apply)
Yes
No
Occasionally
Prescription
Over the counter
Appetite suppressants (natural)
Appetite suppressants (RX)
Laxatives
Do you drink energy drinks?
Yes
No
Coffee consumption
Never
Occasionally
Always
Caffeinated Coffee
Decaffeinated Coffee
Soda consumption
Never
Occasionally
Always
Regular soda
Diet Soda
Caffeinated soda
Decaffeinated soda
Alcohol consumption
Never
Occasionally
Socially
Red wine
White wine
Beer
Liquor
Do you smoke
Yes
No
Whats your favorite fast food:
Do you eat fast foods?
Every day
2-3 times per week
Once a week
Rarely
Never
What were your results:
Have you tried to lose weight in the past?
Yes
No
If Yes, about how many pounds?
5-10 pounds
10-20 pounds
20-50 pounds
50 or more pounds
Do you feel you need to lose weight?
Yes
No
Known Allergies:
List of Vitamins and Supplements:
List all medication and for what condition:
Cancer:
Additional complaints:
Check the following conditions that you currently have or have had in the past:
High blood pressure
High cholesterol
Heart attack
Stroke
Diabetes
Liver disease
Kidney disease
Gall bladder problems
Thyroid problems
Stomach problems
Acid reflux
Digestive problems
Constipation
Celiac disease
Hemorrhoids
Anemia
Urinary tract problems
Frequent urination
Asthma
Allergies (hay fever)
Food allergies
Sinus problems
Tension headaches
Migraine headaches
Vertigo
Sleep apnea
Low Energy levels
Decrease sex drive
Emotional stress
Skin rashes
Joint pains
Arthritis
Swollen ankles
Neck pain
Back pain
Sciatica
Arm/hand pain
Cell Phone:
Age:
Gender
Male
Female
Address:
Name:
*
Email:
*
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