Date  1.
Patient  2.
Relationship to patient if not yourself  3.
Address / country  4.
Tel #  5.
E-mail 6
Height 7
Weight 8
Age 9
M/F 10
What is your main complaint? 11
When did this start? 12
Any reason you can think of that started it? 13
When do problems occur mostly? 14
What time of day or night is worse for you? 15
What do  your symptoms feel like?16
Please feel free to talk as much as you want and to give a much detail as  you wish. 17
The more info I get about you, your actions and feelings, the better. 18

Any problem with vision? 19
What is your complexion like? 20
Moles, warts or freckles,  if so where? 21
Any other skin problems?  Dry? Oily? 22
Anything wrong with nails? 23
Spots, cracks, anything else? 24

Any reactions to weather? 25
Best time of year time? 26
Worst time of year? 27
What weather do you like? 28
What weather do you not like? 29
Dose heat bother you? 30
Does cold or draught bother you? 31
Do you usually feel hot or cold? 32
Any particular fears, as for animals, thunder, ligthnigs  etc? 33
Do you like company 34
or don't like company? 35
Explain. 36
Do you like being comforted 37
or don't like being comforted? 38
Any repeating dreams? 39
In the case that there is what are the dreams about? 40

What is your favourite colour? 41
What shade of the colour? 42
What colours do you not like? 43

What foods do you usually eat? 44
What foods do you crave? 45
What foods do you dislike? 46
What foods make you feel better? 47
What food makes you feel worse? 48
Any allergic reaction from food ? 49
Or to situations? 50
Or chemicals, 51
house hold cleaners, 52
perfume etc? 53

What can you  think of that makes you feel better? 54
Is there anything peculiar about yourself that you can think of? 55
Or unusual habit? 56
Is there any unique symptom that you have? 57
Do you have aches and pains? 58
If so where? 59
when, time of day or night? 60
What do they feel like? 61
What kind of person are you? Happy, sad, busy,  content,  fearful, worry, etc.? 62

The mental and/or emotional state that you live with  is important to explain. 
Like what is your attitude towards life? 63

Do you get depressed? 64
If so, over what kind of things? 65
How is your sleep? 66

Tell about your history in order of time,
include:
Childhood problems? 67
Illnesses? 68
Are you diabetic? 69
Accidents? 70
Operations? 71
Vaccinations? 72
.
Diet: - if you are interested in nutritional advise
Do you take supplements? 73
If so please list which ones? 74
Include, how many times a day.75
What strength are they? 76
Any particular reason why you take the supplements you do? 77

Are you taking any herbs on a regular basis? 78
If so explain what they are what they are for. 79
Are you vegetarian? 80
How many times a day do you eat? 81
Do you eat protein with each meal? 82
Do you use butter? 83
Do you use margarine? 84
Do you eat animal fat? 85
Do you take any essential fatty acid supplements? 86
Are you hypoglycemic? 87
Anything else that you would like to tell me? 88

If you want diet suggestions, then explain what you usually eat.
breakfast 89
lunch 90
dinner 91
snacks 92
If you want supplement suggestions tell me and I will make suggestions 93
Are you specifically interested in anti-aging products? 94
Are you interested in anti-aging cosmetics? 95
Anythinbg else you want to say, please put here. 96
 
 

Payment  for this evaluation $200.00