Full Name
Address
City
Phone Number
*
Email Address
*
Date of birth
Gender
Male
Female
Age
Height
Weight
Status:
Married
Separated
Divorced
Widowed
Single
Partnership
Leave with:
Spouse
Partner
Parents
Children
Friends
Alone
Education
Occupations
Hours Per Week
Retired
Yes
No
Employer
Work Address
In case of emergency, whom should we contact?
Name
Relationship
Address
Phone
How did you hear about the Madison Jules Program?
What are your major complaints and issues? Please list when each symptom began and be as descriptive as possible:
Please list current medications
Please list current vitamins and/or supplements?
Please list your current and past health conditions (i.e. Diabetes Mellitus, etc.):
Is there anything else in your medical history that you consider to be relevant? (Even from childhood)
What is your employment history? Please provide a brief summary including dates if possible.
Please list your past or present Hobbies that could be sources of toxicity or chemicals:
How often are you involved in these Hobbies currently?
Please list past or present allergies, including allergies to medications.
Please list all past surgeries and the condition each surgery was for, including dates.
Please explain your housing history (type of homes, where and when).
What are your short-term and long-term health goals?
Lifestyle
How often do you exercise, and what type of exercise do you engage in?
What is your sleep routine like (average hours of sleep, quality)?
How much water do you drink per day?
Do you consume electrolytes or mineral supplements regularly? Yes or no:
Dietary Preferences:
Do you follow any specific dietary patterns (e.g., keto, paleo, vegetarian)?
Any food intolerances or sensitivities?
Stress and Mental Health:
How do you rate your stress levels on a scale of 1-10?
What strategies do you currently use to manage stress?
SUBMIT