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712 D Street, Suite L
San Rafael, CA 94901
Phone (415) 460-9722 - Fax (415) 454-2866

* Name:
* Date:
* Address:
* Phone:
* Email:
* DOB: (MM/DD/YY) * Age: * Sex:
* Who referred you to us:
* HIPPA Release to electronically transfer my health history data: Yes No
1. Are you currently seeing a doctor? Yes No
2. If yes, please list what you are being treated for:
3. Are you satisfied with the treatment you are receiving from your doctor?
5. What have you done to treat these conditions and did it help?
6.What are you looking for in a holistic health practitioner?
Health Evaluation Quiz
Rate Yourself on a Scale of 1-5 with 1 as the lowest and 5 as the highest

Toxic Exposure:

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Pesticides or inorganic foods

Industrial chemicals use

Hair and nail salon chemicals

Construction field: with carpentry, pressure treated wood,  paint, mortar, grout, sheet rock, sheet rock mud or exposure to asbestos

Occasional to regular use of drugs or alcohol

Long-term medication use

Smoke inhalation

Live in undeveloped country, big city, suburbs


Heavy Metal Exposure:

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5

Field work with petroleum products or vehicle industry

Dentistry metals: amalgam (silver) or recent removal

Canned foods ingestion

Tuna or other fast-swimming fish

Anti-Perspirant deodorant (aluminum) use

Baked goods with baking soda (aluminum)


Toxic Conditions of the Liver:

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3

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5

Alcoholism, medication or drug use

Jaundice (yellow) skin, hepatitis

Gastric distress from fried foods or fats (bloated & gas)

Angered easily or hot-tempered

Diet of packaged food, preservatives, fast foods

Hydrogenated fats found in baked and packaged foods

Exposure to any two categories above


Toxic Conditions of the Colon:

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5

Indigestion, irritable bowels, Crohn's or colitis

Chronic constipation or slow transit time of food (>10 hours to exit)

Bouts of diarrhea or constipation

Frequent gas, foul smelling flatulence or feces

Diet low in natural fiber (< than 5 daily servings of fruits, vegetables)

Consumption of white flour products: pasta, bread, pastries, cakes cookies

Painful belly, gut or distended abdomen


Toxic Condition of the Lungs:

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5

Chemicals or smoke exposure

Industrial chemicals use

Toxic inhalants, such as paint, nail polish remover

Long-term chronic conditions, such as asthma


Kidneys/Adrenals Dysfunction:

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4

5

High-strung or type A personality, can’t slow down to rest

Using caffeine, coffee, chocolate, black or green tea

Heavily salted foods, pork or shellfish

Overweight, fast food diet

Frequent bladder infections

Kidney disease, gout, swelling of feet/ankles

Adrenal exhaustion, chronic fatigue, insomnia

Aching muscles & joints, such as arthritis or bursitis

Frequent inflammations anywhere in the body

History of appendicitis, bronchitis or dermatitis


Skin Toxic Conditions:

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5

Strong body odor during exertion

Acne or other skin eruptions

Cysts or blotchy skin that lacks robustness

Skin problems: psoriasis, dermatitis or skin rashes

Skin cancer


Lymphatic System Toxicity:

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5

Frequent colds/influenza, compromised immune system

Postnasal drip or breathing from mouth vs. nose

Swelling of any part of the body (finger indents in skin)

History of Lyme disease or lupus

Bedridden, immobile or inactive (walk < 30 min. a day)

Women’s health issues, like sensitive fiber-adenoma breast cysts, benign uterine tumors


Poor Digestion with Gas and Bloating:

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2

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5

Craving sugar, carbohydrate (starch, like bread) or chocolate

Coffee addiction (> 2 cups a day)

Hypoglycemia or diabetes history

Candida Albacans (yeast infection) or fungus under nails

Mood swings; self-medicating for depression

Substance abuse or self-medicating with alcohol, marijuana or other drugs or medications


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you to schedule your appointment.

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