If you are a first time client, please fill out this paperwork and bring it with you to your appointment, and fill out the forms below!ACE TestFood Log Name * First Name Last Name Email * Phone * (###) ### #### Message Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Make a timeline of your life. Please start as early as you can remember and if possible even include life events of your family since your conception or birth. Only include major life events and illnesses of yours or others that are close to you. * Please list the supplements, prescriptions, and over the counter medications that you are currently taking along with the strength and frequency. * By signing below, you acknowledge I am not a medical doctor, I do not diagnose, treat or guarantee healing or a cure. I only attempt to help you find what your body is asking for to care for itself. An appointment with me is your decision and any recommendations I give are only recommendations regardless of their nature. You agree that you are seeking services from my business for no other purpose than for your health. I look forward to serving you. * Please list any medical diagnosis that you have * How many hours of sleep do you typically get a night? * How many ounces of water do you typically drink in a day? * What do you usually eat for breakfast? * What do you usually eat for lunch? * What do you usually eat for dinner? * If you snack throughout the day, please list what you eat and how often * How many days a week do you exercise, what type, and for how long? * Would you consider your life stressful or are you going through a stressful time? * What are you hoping to learn or achieve in our time together? * Do you have any known food allergies or sensitivities? * Are you concerned about a particular pain or issue and if so, when did it begin(estimated date and relating to any events)? * For the above question, if applicable, rate your pain on a scale of 1-10 and list the frequency of the pain or issue Have you ever been to a natural healthcare provider? If yes, who? * Please list any family history you are concerned about * What is your occupation? * Relationship status * Single Married Divorced Current Weight * Weight 1 Year Ago * List your health concerns in order of importance * How does your greatest health concern limit you the most? * How committed are you to making valuable changes? * A little Moderately Very Do you take antacids? * Yes No Past If yes, how often? Do you take steroids? * Yes No Past If yes, how often? Do you smoke? * Yes No Past If yes, how many packs per say and how many years? Are you exposed to secondhand smoke? * Yes No Past If yes, please explain Do you take pain relievers? * Yes No Past If yes, which kind? Do you take laxatives? * Yes No Past Do you drink coffee? * Yes No Past If yes, how many cups per day? Do you drink sodas? * Yes No Past If yes, how many ounces per day? Do you have drinks other than water? * Do you take cholesterol medication? * Yes No Past If yes, which one(s)? Do you drink alcohol? * Yes No Past If yes, how often and how much? Are your bowel movements a deep brown color? * Have you had any organs removed? Do you have low or high blood sugar? * Is there a food that you crave or tend to eat a lot? * If yes, how often? Do you feel shaky between meals? * Do you get hangry? * Does the sun hurt your eyes? * Do you have environmental or chemical allergies? * Do you tend to be colder than other people? * How often do you have blurry vision? * How often do you experience sitting to standing dizziness? * How often do you experience nausea? * Do you have jaw pain? * Do you grind your teeth? * Have you experienced hair loss recently? * Do you wake up feeling refreshed? * If you have fatigue, can you still do what you need to during the day? * If you have fatigue, what time of day is worst? If you wake frequently, what is the reason? Do you have low motivation/energy? * Do you have a hard time focusing? * Do you wake up in the night? * If yes, what time typically? What are your hobbies? * Do you tear up easily? * Thank you! New Client Form Symptom Questionnaire Name * First Name Last Name Email * Do you have a bitter metal taste in mouth in the morning? * Never Rarely Weekly Daily Several Times a Day Have you had two or more pregnancies? * Yes No Not Applicable Do you have breast tenderness in menses? * Never Rarely Weekly Daily Several Times a Day Not Applicable Do you have heavy menses? * Never Rarely Weekly Daily Not Applicable Do you have an irregular menstrual cycle? * No Yes Sometimes Not Applicable Do you have hormone imbalance? * Never Rarely Sometimes Regularly Not Sure Not Applicable Do you have PMS? * Never Rarely Weekly Daily Not Applicable Do you have pain on your left side? * Never Rarely Weekly Daily Several Times a Day Do you have low back pain? * Never Rarely Weekly Daily Several Times a Day Do you struggle to lose weight? * Yes No Not sure Do you have acne? * Never Rarely Weekly Daily Do you have psoriasis? * Never Rarely Weekly Daily Do you get rashes? * Never Rarely Weekly Daily Do you have eczema? * Never Rarely Weekly Daily Do you experience pain in your right eye? * Never Rarely Weekly Daily Several Times a Day Do you have pain on your right side? * Never Rarely Weekly Daily Several Times a Day Do you struggle with brain fog? * Never Rarely Weekly Daily Several Times a Day Do you have nutritional deficiency? * Never Rarely Sometimes Regularly Not Sure Do you get leg cramps? * Never Rarely Weekly Daily Several Times a Day Do you have metal fillings? * Yes No Have you had a root canal? * Yes No Do you have yellow palms? * Never Rarely Weekly Daily Do you experience heartburn? * Never Rarely Weekly Daily Several Times a Day Do you get heart palpitations? * Never Rarely Weekly Daily Several Times a Day Do you have Parkinson's Disease? * Yes No Do you get headaches on your right side temple? * Never Rarely Weekly Daily Do you get thirst increase? * Never Rarely Weekly Daily Several Times a Day Do you have dark circles under your eyes? * Never Rarely Weekly Daily Do you have nightmares? * Never Rarely Weekly Daily Do you get sensations in hands and/or feet? * Never Rarely Weekly Daily Several Times a Day Do you have burning feet? * Never Rarely Weekly Daily Several Times a Day Do you have Itchy skin and feet? * Never Rarely Weekly Daily Several Times a Day Does your skin peel on the soles of your feet? * Never Rarely Weekly Daily Do you have scars on your skin? * Yes No Do you get a queasy, nauseous, or 'sick' feeling with unknown cause? * Never Rarely Weekly Daily Several Times a Day Do greasy foods upset your digestion? * Never Rarely Sometimes Always Do you struggle with bloating? * Never Rarely Weekly Daily Several Times a Day Is your stool light in color(in the tan color palette)? * Never Rarely Weekly Daily Several Times a Day Not Sure Do you have floaters? * Never Rarely Weekly Daily Several Times a Day Not Sure Do you have a burning or itching anus? * Never Rarely Weekly Daily Several Times a Day Do you have pain between the shoulder blades? * Never Rarely Weekly Daily Several Times a Day Have you had gallbladder issues or surgery? * Never Rarely Weekly Daily Several Times a Day Yes, surgery Do you have sneezing attacks? * Never Rarely Weekly Daily Several Times a Day Do you get bad breath not resolved by brushing? * Never Rarely Weekly Daily Are you sensitive to hot weather? * Never Rarely Sometimes Always Have you had emotional trauma when you were more than 20 years old? * Yes No Have you had emotional trauma when you were less than 20 years old? * Yes No Are you a worrier or insecure? * Never Rarely Weekly Daily Several Times a Day Do you experience emotional upsets such as sudden: anger, frustration, depression? * Never Rarely Weekly Daily Several Times a Day Do you have neck and/or shoulder pain? * Never Rarely Weekly Daily Several Times a Day Do your ears ring? * Never Rarely Weekly Daily Several Times a Day Do you have itchy ears? * Never Rarely Weekly Daily Several Times a Day Thank you! Name * First Name Last Name Do you feel the anxiety in your body? * Is the anxiety more in your mind(thoughts)? * Do you seek food or drink to relax you? * Does the anxiety seem worse in winter? * Do you have panic attacks? * Do you feel like you have a critic on your shoulder? * Do you have chronic pain? * Do you have 2-3 easy bowel movements a day? * Thank you! Anxiety QuestionnaireIf you have anxiety, please answer these questions Name * First Name Last Name You have insomnia * True False Your Immune System is Fragile * True False You Have Low Sex Drive or Mood * True False You Gain Weight Easily * True False Your teeth decay and gums bleed * True False Your nails have spots, lines, and/or 'spooning' * True False You have unexplained hand or face wrinkles * True False You break out easily and often * True False Thank you! Questionnaire #1 Name * First Name Last Name How often do you experience depression or a depressed mood? * Never Rarely Weekly Daily Several Times a Day Do you sigh frequently? * Never Rarely Weekly Daily Several Times a Day Is it hard for you to concentrate? * Never Rarely Weekly Daily Several Times a Day Do you experience irritability? * Never Rarely Weekly Daily Several Times a Day Do you fidget? * Never Rarely Weekly Daily Several Times a Day Do you struggle with lack of motivation to do anything? * Never Rarely Weekly Daily Several Times a Day Do you experience lack of joy or enthusiasm? * Never Rarely Weekly Daily Several Times a Day Do you feel like your memory is diminished? * Never Rarely Weekly Daily Several Times a Day Do you feel like your memory is diminished? * Never Rarely Weekly Daily Several Times a Day Do you feel fatigued? * Never Rarely Weekly Daily Several Times a Day Do you have fatigue in the afternoon? * Never Rarely Weekly Daily Several Times a Day Do you have muscle weakness or diminished muscle? * Never Rarely Weekly Daily Several Times a Day How often do you get headaches? * Never Rarely Weekly Daily Several Times a Day How often do you get muscle cramps? * Never Rarely Weekly Daily Several Times a Day Do you experience neck stiffness? * Never Rarely Weekly Daily Several Times a Day Do your hands shake? * Never Rarely Weekly Daily Several Times a Day Do you have joint pain? * Never Rarely Weekly Daily Several Times a Day Do you pick at your skin or nails? * Never Rarely Weekly Daily Several Times a Day Do you experience cold intolerance? * Never Rarely Weekly Daily Several Times a Day Do you have facial swelling? * Never Rarely Weekly Daily Several Times a Day Do you struggle with weight gain around the core? * Never Rarely Weekly Daily Several Times a Day Are you sensitive to bright light? * Never Rarely Weekly Daily Several Times a Day Do you have heartburn or reflux? * Never Rarely Weekly Daily Several Times a Day Do you have low or high blood pressure? * Never Rarely Weekly Daily Several Times a Day Do you have a rapid heart rate when resting? * Never Rarely Weekly Daily Several Times a Day Do you have a heart rate below 60 beats per minute? * Never Rarely Weekly Daily Several Times a Day Do you have to urinate frequently? * Never Rarely Weekly Daily Several Times a Day Do you have hot flashes? (if applicable) * Never Rarely Weekly Daily Several Times a Day Do you have painful menses? (if applicable) * Never Rarely Weekly Daily Several Times a Day Do you have gas and bloating? * Never Rarely Weekly Daily Several Times a Day Do you experience alternating constipation/ diarrhea? * Never Rarely Weekly Daily Several Times a Day Do you have constipation? * Never Rarely Weekly Daily Several Times a Day Do you have diarrhea? * Never Rarely Weekly Daily Several Times a Day Do you have dark colored urine? * Never Rarely Weekly Daily Several Times a Day Thank you! Questionnaire #2 Name * First Name Last Name Being anxious, shy, or fearful or experiencing inner tension since childhood, but hiding these feelings from others * Having bouts of depression or nervous exhaustion * Poor dream recall, stressful or bizarre dreams, or nightmares * Avoiding stress because it upsets your emotional balance * Tending to become dependent on one person whom you build your life around * Preferring the company of one or two close friends rather than a gathering of friends; becoming more of a loner as you age * Feeling uncomfortable with strangers * Being bothered by being seated in the middle of the room in a restaurant * Being easily upset by criticism * Difficulty recalling past events and people in your life * Focusing internally, on yourself, rather than on the external world * Feeling stressed by changes in your routine, such as traveling or being in new situations * Excessive reactions to tranquilizers, barbiturates, alcohol, or other drugs, in which a little produces a powerful response * Preferring not to eat breakfast, experiencing light nausea in the morning, or being prone to motion sickness * White spots or flecks on the fingernails or opaquely white or paper-thin nails * Joints popping, cracking, or aching; pain or discomfort between the shoulder blades; or cartilage problems * Being sensitive to bright sunlight or noise * Upper abdominal pain on your left side under the ribs or, as a child, having a stitch in your side as you ran * Frequent fatigue * Being prone to iron anemia * Tending to have cold hands or feet * Having frequent colds or infections, or unexplained chills or fever * Reaching puberty later than normal or having irregular menstruation or PMS * Having allergies, adrenal issues, or problems with sugar metabolism * Having gluten sensitivity * Stretch marks or poor wound healing * Crowded upper front teeth, many cavities, or inflamed gums or wearing braces * Bad breath and body odor (or a sweet, fruity odor), especially when ill or stressed * Being prone to acne, eczema, herpes, or psoriasis * Reduced amount of hair on your head, eyebrows, or eyelashes, or prematurely gray hair * Tending to have morning constipation * Tingling sensations or muscle spasms in your legs or arms * Feeling stressed by changes in your routine, such as traveling or being in new situations * Your face looking swollen when you’re under a lot of stress * Cluster headaches or blinding headaches * Poor appetite or having a poor sense of smell or taste * Disliking protein or having ever been a vegetarian or vegan * For women, belonging to an all-girl family or having look-alike sisters * For men, having a mother from an all-girl family or a mother with look-alike sisters, or all the females in the mother’s family bearing a strong resemblance to each other * Thank you! Questionnaire #3Please write 0-10, with 0 being never and 10 being always
