Health Survey

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* Name:
Address:
City/State/Zip:
* Email:
Telephone:  Home Mobile
Do you text?
Best time to reach you:
Best time to have a consultation:
Date of Birth:
Marital Status:
Number of children:
The ages and general health of your children:
What is your approximate weight and height?
Do you know your BMI (Body Mass Index)?
Are you happy with your current weight?
In general, would you say your health is:
 Excellent Very Good Good Fair Poor
Do you suffer from any chronic disease states? If Yes, what, and for how long?
Have you had any surgeries or procedures? What and when?
Compared to one year ago, how would you rate your health now?
 Better The Same Worse
Do you take any pharmaceutical medications? (list them):
Do you take any supplements or herbal combinations? (list them):
Do you take or use any other non-pharmaceutical products? (list them):
Do you have any known allergies to foods, chemicals, or medications? (list them):
How much bodily pain have you had in the past 4 weeks?
 None Mild Moderate Severe
If Yes, to bodily pain, where and for how long?
In the past 2 months have you experienced:
 Fatigue
 Nervousness
 Memory Problems
 Feeling Downhearted/Sad
 Tired/Worn Out
 Rashes
 Weight Gain or Loss
 Conflicts with Friend or Family
 Major Changes {death, a move, job change, divorce, etc.
Do you exercise at least 3 times a week? What is your exercise choice?
Enter everything you have eaten or had to drink in the past 24 hours:
What is your job/profession?
What kinds of known exposures do you have to chemicals at home or work? For example, do you touch ink on receipts, do you mix or work with any kinds of chemicals, are you a welder, a painter, do you drive to work in heavy traffic, do you fly often, do you use cleaning products, are you around nail polish, or hairspray, do you repair engines, are you around pesticides, do you work with plastics, etc?
(The Center for Disease Control/CDC says the average American harbors an average of 212 toxins in their body tissues…so we are all toxic to one degree or another. I just want to help you figure out if you have specific exposures known to be present at your job site.)
Have you ever done any kind of detoxification process/method? If so, what and when?
On a scale of 1 to 10…1 being no stress, and 10 being totally overwhelmed…what would you consider your over all stress level to have been for the past month? What do you do, that is helpful to you, for handling stress?
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Thank you for completing this survey! This will be a great starting place for us to discuss how I can help you to create both your Personal Detox Plan, and your Personal Plan for Optimal Health.

*All information contained in this Survey is confidential. This form will be kept in strictest confidence, never shared with anyone, and only discussed with you.

Vicki Latham, P.A.-C.

Health Survey Form (click to access and print the PDF version of the above form.)

“If newborns are toxic, what chance do we adults have of being toxin clear?”

Understanding that we can detoxify our bodies daily with effective options that are easy, simple and inexpensive to do…this is the purpose of the ToxinClear movement.

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