Health Survey

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Webinar Invitation for Toxinclear
You are invited to attend this 30 minute, on line webinar event. Title: You don’t have to gain 5 lbs this Holiday season! Time: Date, Time, and web site location to follow soon. Listening method: Phone + Web Simulcast Phone number PIN Code To attend, visit: Presented by: Vicki Latham, PA-C For …Read More »
Has it really come to this?
During my most recent trip to California, I was offered a free breakfast with my motel room. On the back of the menu, I found this shocking notice: Warning: Chemicals Known To The State of California To Cause Cancer, Or Birth Defects, Or Other Reproductive Harm May Be Present In …Read More »

Vicki Latham, P.A.-C. is a Board-Certified Physician Assistant with 31 years experience in both traditional and alternative medicine from 1980 to present, including 9 years as the Women’s Health Practitioner at Oklahoma State University. Vicki’s medical practice also included Internal Medicine, and OB/GYN; delivering over 500 newborns. She developed a passion for helping Diabetics, while working Emergency/Adult medicine for the U.S. Indian Health Service. Vicki lectures throughout the world on environmental toxicity and how it impacts our health issues. Her passion is to assist others in creating their own, uniquely Personal, Optimal Health Plan.

Your email address will not be published. Required fields are marked *
* Name:
Address:
City/State/Zip:
* Email:
Telephone:	HomeMobile
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:
	ExcellentVery GoodGoodFairPoor
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?
	BetterThe SameWorse
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?
	NoneMildModerateSevere
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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From the Blog

Webinar Invitation for Toxinclear

Has it really come to this?