Intake / Self Assessment Form

Your Name (required)

Your Email (required)

Your Telephone (required)

Your Birth Date

Your Sex

Your Height

Your Weight

Your Eating Style

Do you smoke?

If you smoke, enter number of years, and packs or cigarettes per day

Your Marital Status

Recent Weight Change if Increased

Recent Weight Change if Decreased

Period of Time for Weight Change

Profession

Job Responsibilities

Exposure to Computers in Hours/Day

Exposure to Chemicals at place of work at any time in the past (describe)

Weak Eye Sight (describe)


FEMALES:

Check box in front of each symptom that you have:
PMS / CrampsMenopausal SymptomsHeadaches / MigrainesMood swings / DepressionInability to Lose WeightFatigueFoggy Thinking / Memory LossLost Interest in SexWater Retention / bloatingLow Blood SugarAdult AcneLower Back PainsHypothyroid / HyperthyroidIrregular CyclesLowered LibidoBreast TendernessPanic / WeepingBlood Sugar ImbalanceLeg / Muscle CrampsFeelings of Being CrazyUterine FibroidsAllergiesFacial HairLow Thyroid SymptomsSciatica (Lower Back / Leg Pain)Hot / Cold FlashesBone Loss (Osteoporosis)Swollen Feet / AnkleVaginal DrynessHair LossFibrocystic BreastAnger / IrritabilityUterine FibroidsAge and Liver spotsDry Aging SkinInsomniaSpondylitis (Upper Back Pain)

Other Female Symptoms

Describe Periods (Irregular Periods / Non Ovulating Cycles / Have the number of days of flow reduced to less than typical 4 day period normally encountered in most women)

Year of Puberty

Year of Menopause

Year of Hysterectomy

Date of Last Menstrual Period

pH

Bleeding Time

Blood Pressure

Pulse


MALES:

Check box in front of each symptom that you have:
Difficulty Passing UrineImpotenceErectile DysfunctionProstate InflammationEnlarged ProstateProstate CancerIncontinenceBurning Sensation UrinatingHeadaches / MigrainesMood swings / DepressionInability to Lose WeightFatigueFoggy Thinking / Memory LossLost Interest in SexLack of Sex DriveWater Retention / BloatingLow Blood SugarAdult AcneReduced Muscular StrengthLower Back PainsHypothyroid / HyperthyroidLowered LibidoPanic / WeepingBlood Sugar ImbalanceLeg / Muscle CrampsFeelings of Being CrazyHysteriaAllergiesLow Thyroid SymptomsLow Sperm CountSciatica (Lower Back / Leg Pain)Breast EnlargementRapid Weight LossHypoglycemiaHair LossAnger / IrritabilityAge and Liver spotsDry Aging SkinInsomniaDiabetesSpondylitis (Upper Back Pain)

Other Male Symptoms


MALES AND FEMALES:

Your Medical History

History of Constipation / Loose Motions / Indigestion, Bloating, Gas, Acidity, Impotence / Lack of Sex Drive / Urinary Problems

Present Symptoms

Chronic Health / Beauty Challenges you would like to overcome

If you use a Pacemaker, Defibrillator or are Pregnant please inform us now before you start treatment for Spondylitis or Sciatica / Pain Relief / Vita Flex Therapy

List of Present Medications (name, dose, how long taken, for what ailments)

List of Present Supplements (name, dose, how long taken, for what ailments)

List of Past Medications (no longer using)

Referred to WakeupSense by

Your Remarks