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First Name*

Address*

Email Address*

Birth Date*

Height*

Weight*

Gender*

Last Name*

Phone Number*

City*

State*

Zip Code*

Today's Date*

Occupation*

Describe Problem(s)*

What treatments have you tried?*

Has anything been successful?*

With whom do you live?*

(Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister

Do you have any pets of farm animals? If yes, where do they live?*

Example: indoors/outdoors

Have you lived or traveled out side of the United States? If so, when and where?*

Have you or your family recently experienced any major life changes? If yes, please comment:

Have you experienced any major losses in life? If so, please comment:

How much time have you lost from work or school in the past year?

Phone Number

Previous jobs:

Have you been involved in abusive relationships in your life?*

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *

Do you feel safe, respected and valued in your current relationship? *

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *

Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues? *

Please list any allergies or intolerances (food or environmental): *

List past Medical and Surgical History: *

List previous hospitalizations: *

How often have you taken antibiotics? *

How often have you have taken oral steroids? *

What medications are you taking now? (including birth control/hormones) *

List all vitamins, minerals, and other nutritional supplements that you are taking now. *

Were you a full term baby? A preemie? Breast-fed or Bottle-fed? *

As a child did you eat a lot of sugar and/or candy? *

What is your typical daily diet: *

Are you on a special Diet?  *

Is there anything special about your diet that we should know?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? *

Do you feel much worse when you eat certain foods? *

Does skipping a meal greatly affect your symptoms? *

Have you ever had a food that you craved or really "binged" on over a period of time? *

Do you have an aversion to certain foods? If yes, what foods? *

How many bowel movements (BM) do you have per day? *

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? *

Do you have intestinal gas? If so, when. *

How many times per week do you drink alcohol? *

Have you ever used recreational drugs?

Have you ever used tobacco? (If so, for how long?) *

Are you exposed to secondhand smoke regularly? *

Do you have mercury amalgam fillings in your teeth? If so, how many? *

Do you have any artificial joints or implants? If so, which ones.

Do you feel worse at certain times of the year? *

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

Do odors affect you? If so, which ones?

How would you rate your current level of stress? *

Women: If you have a cycle, how long is it and is it regular?

Women: Do you have any problematic symptoms related to your cycle?

Women: Any other comments related to your cycle? (flow, clots, mood changes, etc.)

Have you ever had psychotherapy or counseling?

List your hobbies and leisure activities: *

Do you exercise regularly? If so, how many times a week? *

What type of exercise is it?

Do you struggle with insomnia or interrupted sleep?

Do your parents or siblings have (or had) any health issues? If so, please explain:

Please add any other information you feel is important:

I have read and understand everything on this page. I acknowledge Matthew Madden and his associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Matthew Madden, his lab partners, his independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.

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