Your Wellness Biography – Your Labwork – Leading Authority in Thyroid Treatment

Name*
First Last
Email*
Phone*
Arthritis
Self Parent Grandparent Sibling
Allergies/sinus
Self Parent Grandparent Sibling
Cancer/Type
Self Parent Grandparent Sibling
Diabetes
Self Parent Grandparent Sibling
Heart disease
Self Parent Grandparent Sibling
Thyroid disorder
Self Parent Grandparent Sibling
Other
Self Parent Grandparent Sibling
Gastro disease
Self Parent Grandparent Sibling
Women
Last Pap
Date Format: MM slash DD slash YYYY
Mammogram
Date Format: MM slash DD slash YYYY
Menses
Date Format: MM slash DD slash YYYY
DEXA
Date Format: MM slash DD slash YYYY
Colonoscopy
Date Format: MM slash DD slash YYYY
Hysterectomy
- Yes
- No
Men
Last Digital Rectal Exam - Prostate health
Date Format: MM slash DD slash YYYY
Colonoscopy
Date Format: MM slash DD slash YYYY
Drug or Food Allergies
Please list all current prescription medications, over the counter meds, herbs and dietary supplements you take:
Medication/ Supplements Dosage Purpose How long have you taken it Side Effects
To what extent are you open and willing to make changes in your lifestyle and diet?
- Not Open to Change
- Somewhat Open to Change
- Very Open to Change
Context of Care Review
What is your expectation of Integrative Health?
Whom or What helps you daily?
What is holding you back?
What do you love to do?

Self	Parent	Grandparent	Sibling

Self	Parent	Grandparent	Sibling

Self	Parent	Grandparent	Sibling

Self	Parent	Grandparent	Sibling

Women