Wellness Essentials, LLC

Wellness Essentials, LLC 456 N. Main Street, Oshkosh, WI 54901 (920) 410-4022, [email protected] Please answer the following questions: This data is used for stress reduction only. 1. Have you had any organs removed? No _____ Yes _____ …….Total # organs removed _____ a. If Yes, please list: ______2. Do you take any prescription medication? No _____ Yes _____ …Total # prescriptions _____ a. Please complete intake form regarding prescriptions and supplements. It is important to be informed of stressors related to potential side effects of medication and supplements. 3. Do you use tobacco? No _____ Yes _____ What type: ______....Total # a day _____ 4. Have you taken any steroid medications in the past year? No _____ Yes _____.....Total # _____ a. Examples: cortisone creams for rashes, prednisone, inhaler 5. Do you have any metal amalgam fillings in your teeth? No _____ Yes _____...... Total # _____ a. Metal amalgams are the dark fillings in your teeth. If removed, when: ______6. Have you used any street drugs in the past year? No _____ Yes _____...... Total # _____ 7. Do you have any allergies to plants, foods, medications? No _____ Yes _____...... Total # _____ a. Please list: ______8. How many unresolved issues impact your life? ………………………………….. .Total # _____ a. These are things that may make you sad, angry, feel grief, depressed, agitated, or unhappy. b. These things may bother you daily, once a year, on a specific date, and/or may be associated to a sound or person or event. 9. On a scale of 1-10, how responsible are you for your health (10 = 100%) ______% 10. What percentage of fat do you eat in your daily diet? ______% a. The average American consumes 40% fat daily. There are good fats – avocados, nuts, olive oil, coconut oil 11. What is your typical stress level on a scale of 1 – 10, 10 being max? ______12. How many items with processed sugar do you eat a day? ______i. Examples: Cereal, yogurt, candy, sweetened drinks, jam, Danish, cookies, etc. b. How many items with wheat to you eat a day? ______i. Examples: Bread, pasta, donuts, cereal, granola, etc. c. How many items with artificial sweeteners do you consume a day? ______i. Examples: low calorie, low carb, low fat, “diet” ii. Please list artificial sweeteners used: ______13. How many times do you exercise a week at least 20 minutes or more? ______a. Please list types of exercise: ______14. How many alcoholic drinks do you drink a day on average? ______A week on average? ______15. How many 8 ounce servings of regular coffee or caffeinated tea do you drink a day? ______a. If you eat chocolate, how much chocolate do you eat a day? ______...... A week? ______16. How many toxic exposures have you had in the last year? ………………………..Total # ______a. Toxic exposures include x-rays, pesticides, molds, & chemicals. 17. Please list the number of injuries you have had in your life time: …………………Total # ______a. Injuries include car accidents, broken bones, hard falls to the head/tailbone, and emotional traumas (loss of a loved one, abuse, divorce, relationship issue, etc.) Please list with dates: i. Car accidents: ______ii. Broken bone(s): ______iii. Injury to tailbone/head: ______iv. Emotional Traumas: ______v. Surgeries: ______18. How may times have you taken antibiotics in your lifetime (guess): ______19. How many 8 ounce glasses of pure water do you drink a day? ______20. Do you think you are overweight? No _____ Yes _____ Total # pounds overweight ______

Name: ______Date: ______