Please Fill Out All Text Boxes Below Name* First Last Email* List your chief complaints in order of importance to you.*Provide a detailed narrative (story) of your health history in a timeline sequence.*Example: 1990 – C-Section Birth with forceps 1995- Received anti-biotics for pink eye and had a bad skin reaction from this. 1997- Diagnosed with Mononucleosis. 2000- Motor vehicle accident. Broke femur. 2001- Had first child. Normal birth, no complications. 2003- Visited another country and got diarrhea and lightheadedness from something there. 2008- Started having IBS symptoms all the time. List all diagnoses given to you in a timeline sequence and your personal opinions about the diagnosis*What is your opinion of what has happened to your health?*List of all healthcare providers you have consulted and their opinions and treatments about your case.*List any treatments, medications, or supplements that have IMPROVED your health.*List any treatments, medications, or supplements that have caused reactions or DECREASED your health.*List in a timeline sequence any medications you have taken.*List in a timeline sequence any exposure to environmental, industrial, or toxic compounds*List any history of infections (Excluding common colds)*List ALL current medications, herbs, vitamins, supplements, etc*Describe your family’s medical history. (mom, dad, grandparents, siblings.)*Have you ever had symptoms after being bitten by an insect or arachnid? When? Explain the symptoms.*Does it feel MUCH better when you go on vacation?*Have you ever lived or worked in a water damaged building. What years?*Why do you think healthcare practitioners have been unsuccessful with your case?*Do you think your condition can be cured or improved?*What do you consider a realistic time frame to see changes in your health under our care?*What are your expectations from us?*Is there anyone or anything you blame for your health condition?*What specific improvements in your health would you consider a successful outcome in your case.*Is there anything you feel you should tell us about yourself or your case that you haven’t already?*Is there anything in what you believe about health and the body that you may think is holding back your health?*Are you willing to change what you believe about health and the body in order to get better and stay better?*Are there any emotional experiences or emotional traumas that could be affecting your health condition?*Do you have a distinct purpose in life? Are you fulfilling it?*Is your spouse and/or family unit supportive of you with your health condition?*Is your spouse and/or family unit supportive of you seeking care at our office?*How did you feel about answering all these questions?*CommentsThis field is for validation purposes and should be left unchanged.