Tree of Life Forms
Initial Health Form
Step
1
of
4
- Patient Information
25%
Patient's Name
(Required)
First
Last
Email
Phone
Address
Optional. This will help us know where to send any remedies.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth
(Required)
MM slash DD slash YYYY
Sex
Male
Female
Prefer not to say
Job/Occupation
Current Height
Current Weight
What weight are you most comfortable at?
Considering your overall health, list your biggest health concerns or symptoms and when they started:
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How often do you consume the following per week?
Soda Pop
Grains
Coffee
Alcohol
Fast Food
Dairy
Fruit
Vegetables
Meat / Poultry
Fish
Nuts / Seeds
Cigarettes
Sweets
Beans / Legumes
Hidden
Empty 1
Hidden
Empty 2
What recreational drugs to you use (if any)?
Any foods that you crave?
Salty foods
Chocolate
Sweets
Bread
Other
Other cravings:
How many times per week do you exercise?
0
1
2
3
4
5
6
Everday
Describe your most common exercise:
How many ounces of water do you drink daily?
How many bowel movements do you have a day?
Are your bowel movements
Loose
Well formed
Incomplete
Thin
Dry and Hard
Painful
Diarrhea
Need Laxatives
Are you currently pregnant?
Yes
No
Are you currently a nursing mother?
Yes
No
How many hours of sleep do you get at night?
At night, Is it difficult to fall asleep? Or back asleep?
On a scale from 1 to 5, 5 being the highest level of energy, how much daily energy do you have?
1
2
3
4
5
Select your most common feelings or emotions
Nervous
Happy
Obsessive
Stuck
Confused
Angry
Content
Irritated
Other
Other emotions:
List all allergies:
List any major illnesses or surgeries you've had and how long ago:
List any mental or emotional disorders you have been diagnosed with:
Please list all current medications and supplements as well as why you're taking them:
Select any health issues you currently have:
Acid reflux
Acne
ADD/ADHD
Alcoholism
Allergies
Alzheimer's
Arteriosclerosis
Arthritis/Joint Pain
Asthma
Bipolar
Bladder issues
Bloating
Cancer
Candida
Cholesterol
Colities/IBS
Constipation
Crohn's
Diabetes
Dizzy spells
Ear infections
Ear ringing
Edema
Emphysema
Epilepsy
Gallstones
Hair issues
Heart disease
Heartburn
Hemorrhoids
Herpes
High blood pressure
Hives
Hormonal imbalances
Hypertension
Hyperthyroidism
Hypoglycemia
Hypothyroidism
Hysterectomy
Impotence
Incontinence
IUD, path, ring, or other oral contraceptive
Kidney Disease
Kidney stones
Liver disease
Low blood pressure
Lupus
Lyme Disease
Menopause
Menstrual Cramps
Mental health
Migrains
Miscarriage
Mononucleosis
Multiple Sclerosis
Nausea
Neuropathy
Nose bleeds
Pacemaker
Parkinson's
PMS
Prostate issues
Reproductive issues
Seizures
Shingles
Sinus Issues
Skin issues
Stroke
Ulcers
Urinary infections
For all issues selected, please note when they started:
On a scale from 1 to 10 (10 being very familiar), how familiar are you with holistic/natural living?
Special considerations for remedies
i.e. Vegan Friendly, Alcohol Free, Liquid Only, etc
Today's Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
By submitting this form, whether it is signed or not, I fully understand that our proprietary testing service deals strictly in helping improve general health through better nutritional approaches, improved lifestyle, improved health habits and positive mental attitudes. I fully understand that employees of our proprietary testing service are not licensed physicians and cannot diagnose diseases, prescribe drugs or recommend treatments for specific disease conditions. I understand that all evaluations/analysis performed by are designed to evaluate my inherent constitution and temperament for the sole purpose of helping me to improve my general health through nutrition, habits, and attitudes. I further understand that all evaluations/analysis cannot determine specific disease conditions, and do not replace the diagnostic services offered by licensed physicians. I certify that our proprietary testing service has not suggested that I cease any medical care I may be undertaking. I understand that decisions I make regarding health care are my responsibility and certify that I will not hold our proprietary testing service responsible for the consequences of my decisions. These services are not a substitute for prompt medical attention needed. Natural attempts will be made to relieve discomforts, but if a medical professional is needed, seek medical attention or verify recommendations with a primary physician. I certify that I am here on this and on any subsequent visits or contact, whether by mail, telephone, or in person, solely on my own behalf and not as an agent or representative of any federal, state, county, or local government or private agency on a mission of investigation. I have read and understand the foregoing and agree to the terms and conditions set therein. Your privacy is a top priority. We are committed to your Confidentiality of personal information, and securing it with administrative, technical, and physical safeguards. None of your information will ever be sold.
I agree to the terms and conditions