LBCA Health Form

Email Address (required)

Address (required)

City (required)

Province/State (required) Canadian Province or USA State

Postal/Zip Code (required)

Home Phone Number (required)

Cell Phone Number (required)

Date of Birth (required)

Gender (required)

Female Male for a Male Child for a Female Child

Height and Weight (required) Ft/Inches and LBS

Status (required)

5 Main Concerns (required) These are concerns you would like addressed or have current health issues with

Family Health History (required) Grandparents, Parents, Siblings, Genetics

Personal Health History (required) Childhood Illnesses, Vaccinations, Accidents, Surgeries, Diagnoses

Women Only - Menstrual Health (required) Hormonal / Child Bearing — Start of Menstruation, # of Children, Vaginal or C-Section, Issues, Hysterectomy, Peri/Menopause

Non/Smoker (required)

Alcohol/Drug Current Use or History (required) If current, drinks per day or week, Drug of choice, Past Use

Occupation (required)

Computer Use Duration/Day (required) Computer, cell phone use, average daily hours

List of Medications (required) Prescribed, Over the Counter, Dosage, Frequency, Reason, Length of Time

Current Supplements (required) Brand Name, Dosage, Frequency, Reason, Length of Time

Activity Level (required)

No Exercise 1 - 2 / Week 3 x Week 4 -7 / Week Active on the Job Very little activity at Job Cardio Strength Training Mind/Body

Oral Health (required)

Dental Carries Silver Amalgms Gum Disease Root Canals Dry Mouth

Sleep Routine (required) Hrs/Night, Time to Bed, Time Awake, Feel Rested, Nap during day

Stress Level (required)

Number of Bowel Movements (required) Frequency

Bowel Consistency (required)

Bowel Contents (required)

Stringy/Mucous Floating/Fat Blood - Red Undigested Food Particles Sinks

Length of Stool (required)

Bowel Width (required)

Bowel Texture (required)

Bowel Colour (required)

Bowel Time (required) From time you sit on Commode to Release

Toilet Paper Use (required) Amount needed

Radiation Exposure (required)

Live near Nuclear Reactors Live Near Cell Towers or Transformer Stations Microwave Use Electric Blanket Use or Water Bed Computer/ Cell Phone Frequent Airplane Travel Sleep near Smart Meter

Chemical Exposure (required)