Email *
Address *
City *
Province / State *
Postal Code / Zip Code *
Country *
Phone Number *
Time Zone *
Age *
Place of Birth *
Height *
Weight *
Gender *
Describe Problem(s) *
What treatments have you tried? *
Has anything been successful? *
Have you lived or traveled overseas? If so, when and where? *
Have you or your family recently experienced any major life changes? If yes, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you lost from work or school in the past year?
Please list any allergies or intolerances (to medications, food or environmental): *
List past Medical and Surgical History: *
List previous hospitalizations: *
What medications are you taking now? (including birth control/hormones) *
List all vitamins, minerals, and other nutritional supplements that you are taking now. *
Were you a full term baby? A preemie? Breast-fed or Bottle-fed? *
As a child did you eat a lot of sugar and/or candy? *
Are you on a special diet? *
Is there anything special about your diet that we should know? *
Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? *
Does skipping a meal greatly affect your symptoms? *
Have you ever had a food that you craved or really "binged" on over a period of time? *
Do you have an aversion to certain foods? If yes, what foods? *
Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? *
Do you have intestinal gas? If so, when? *
How many times per week do you drink alcohol? *
Have you ever used recreational drugs?
Have you ever used tobacco? (If so, for how long?) *
Are you exposed to secondhand smoke regularly? *
Do you have mercury amalgam fillings in your teeth? If so, how many? *
Do you have any artificial joints or implants? If so, which ones? *
Do you feel worse at certain times of the year? *
Have you, to your knowledge, been exposed to toxic metals in your job or at home? *
Do odors affect you? If so, which ones?
How would you rate your current level of stress on a scale of 1-10? *
Women: If you have a cycle, how long is it and is it regular?
Women: Do you have any problematic symptoms related to your cycle?
Women: Any other comments related to your cycle? (flow, clots, mood changes, etc.)
Have you ever had psychotherapy or counselling?
List your hobbies and leisure activities: *
Do you exercise regularly? If so, how many times a week? *
What type of exercise is it?
Do you struggle with insomnia or interrupted sleep? *
Do your parents or siblings have (or had) any health issues? If so, please explain:
Please add any other information you feel is important:
Why do you believe you would be a good candidate to work with Melissa Deally? *