• Name *
    First
    Last
     
  • Email address *
  • Address *
    Street Address
    Address Line 2
    City
    State / Province / Region
    Zip / Postal Code
    Country
     
  • Phone
    (###)
    -
    ###
    -
    ####
     
  • Reason for consult *
  • If you could change 1 thing about your health or physical appearance it would be.....?
  • Date of Birth
    MM
    /
    DD
    /
    YYYY
     
  • Weight
    Fill in your current body weight
  • Height
    Enter your height in inches
  • List medications
    List all medications you are currently taking or have taken in the last 6 months and why they were prescribed (including birth control)
  • List your current Doctor(s) *
  • What is your Occupation? *
  • Are you currently or have you been in the past, subject to toxic exposure? *
    For Example: Grew up on a farm, Worked in a print shop, plastics factory, steel mill. Lived beside a manufacturing facility.
  • Father's Occupation
  • Mother's Occupation
  • Hobbies & Physical Activities you participate in
  • List any known allergies past or present
  • List all supplements you are currently taking and what you take them for:
  • Do you exercise?
  • How many times per week and how long per session?
  • Do you currently use a trainer? if yes please list.
  • Do you Drink Alcohol
    Yes
    No
  • What type?
    Liquor
    Beer
    Wine
  • How much water do you drink in a day?
  • Water
    Bottled/Filtered
    Tap
    Distilled
  • Do you drink diet soda? *
    Regularly
    Occasionally
    Never
  • Check all that apply to your parents
    Diabetes
    Heart Disease
    Heart Attack
    Cancer
    Auto Immune Disease
    Alzheimer's
    Obesity
  • Check all that apply to your Grandparents
    Diabetes
    Heart Disease
    Heart Attack
    Cancer
    Auto Immune Disease
    Alzheimer's
    Obesity
  • Were you breastfed?
    Yes
    No
    Don't know
  • Does the smell of perfume or lotions bother you?
    Yes
    No
  • Does cigarette or campfire smoke irritate you?
    Yes
    No
  • Can you fall asleep after drinking a cup of cofee?
    Yes
    No
    Don't drink coffee
  • Do you feel very wired/jittery after drinking a cup of coffee?
    Yes
    No
    Don't drink coffee
  • Does your urine have a foul odor after eating asparagus?
    Yes
    No
    Don't know
  • When was the last time you took antibiotics?
    Within the last 3 months
    Within the last 6 months
    Within the last year
    Check all that apply
  • What antibiotic and what were they for?
  • Do you experience joint pain?
    Yes
    No
    Only when I exercise
  • Arthritis
    Yes
    No
  • How many times have you had a cold in the last year? *
    None
    One
    Two
    Three
    Four or more
  • Have you had the flu in the last year
    Yes
    No
  • Do you exeperiance?
    Anxiety
    Depression
    Severe mood swings
    Uncontrollable sugar craivings
    Heartburn
    Indigestion
    Bouts of anger
    Headaches
    Obsessive/Compulsive Behavior
    Bursts of energy
    Check all that apply
  • How often do you experience migraines?
    Never
    More than 4 times per month
    Occasionally
  • What time do you go to bed?
    HH
    :
    MM
    :
    SS
     
  • What time do you wake up for the day?
    HH
    :
    MM
    :
    SS
     
  • What time(s) do you get up during the night to use the bathroom?
  • Do you *
    Have a hard time falling asleep?
    Have a hard time staying asleep?
    Take something to help you sleep?
    Sleep like a rock!
    Check all that apply
  • How many times per week do you have a bowel movement?
    One to three
    Five to Seven
    More than seven
  • Check all items that you currently have or have had in the past *
    Digestive Issues
    Auto Immune Disorder
    IBS
    High blood pressure
    High cholesterol
    Chicken Pox
    Appendicitis
    Kidney Stones
    Diabetes
    Mononucleosis
    Shingles
    Gallbladder issues/removed
    Chronic Joint pain
  • Health Timeline -This is important. Fill it in! *
    Provide a history. Example: Had chicken pox at age 5, ear infection at age 7. Diagnosed with ADD at age 8. Noticed a decline in energy at age 27. Started getting allergies around age 30 after moving, etc.
  • Do you keep electronics in your bedroom?
    This includes cell phone, computer, TV, components, etc
  • Have you experienced a traumatic event?
    Can include surgery, divorce, death of someone close, financial trouble. etc
  • Have you been exposed to mold & does your home or office have mold?
  • Are you sensitive to mold?
  • Do you have any silver fillings?
    Yes
    No
  • Do you have any crowns?
    Yes
    No
  • Have you ever had a root canal? *
    Yes
    No
  • Have you been bitten by a tick or spider?
    Yes
    No
    Not sure
  • Do you use artificial sweetners? *
    Yes
    No
    Occassionally
  • Does the smell of chemicals, cleaners, auto exhaust bother you? *
    Yes
    No
  • Do you have dry, flaky skin? *
    No
    Occasionally
    Yes
    I can create a snow flurry by rubbing my skin
  • Do you have dry, chapped lips? *
    Yes
    Occasionally
    No
  • Do you snore or puff breathe? *
    Yes
    No
    Don't Know
  • Does your sweat smell like ammonia? *
    Yes
    No
    Don't Know
    Don't sweat
  • Have you ever noticed a 'Maple Syrup' smell on yourself? *
    Yes
    No
    Don't Know
  • How did you hear about us?
    Referral (who?) website, google, gym, etc
  • Jared Olson does not diagnose, cure or treat any illness or disease. He is not a Doctor. *
    I have read and understand the above