Your Cell Number *
May I text you? * Yes No
Email *
Age *
Date of Birth *
Sex * < select answer > Female Male
City & State *
Height: *
Current Weight: *
Current Health Concern – Please provide as much detail as you can. *
Do you eat breakfast daily? * < select answer > Yes (daily) No Sometimes (3-5x per week)
Do you follow any specialized diet(s)? Example: Fasting, Paleo, Keto, Vegan, Vegetarian, Carnivore, Atkins, Whole30, etc. Please explain. *
Your Health Information – Please explain if above selections are current or past issues. Provide any information that may help me understand your current health. *
Health History – Please describe any past health issues. *
Have you ever been pregnant? * < select answer > Yes No
How many pregnancies have you had in total? *
How many full term births? *
Allergies (including medications, foods, environmental, seasonal, etc.) *
Medications / Supplements / Vitamins / Herbs – Please list all (including over the counter) along with dosages and how often you take. *
Do you currently smoke? * < select answer > Yes No
How many cigarettes do you smoke in a single day? *
How long have you been a smoker? *
Do you currently have mercury fillings in your teeth (black/gray or silver)? **please check your mouth for these fillings * < select answer > Yes No I don't know
Have you had any mercury (black/gray or silver) fillings removed in the past? * < select answer > Yes No I don't know
Have you had any tooth extractions (teeth pulled), including wisdom teeth? * < select answer > Yes No I don't know
Do you have any tooth implants? * < select answer > Yes No I don't know
Do you have any root canals? * < select answer > Yes No I don't know
Have you had an abcess (an antibiotic required infection in your gums or teeth)? * < select answer > Yes No I don't know
Did your Dentist tell you that you have receeding gums? * < select answer > Yes No I don't know
Please briefly explain any "yes" answers to the dental-related questions above. *