Physical

   

Your Blood Type:                                Strength:   

 

Metabolism:      Blood Pressure:

 

Current Health:     Childhood Health: 

 

Sleep Pattern

  

How many hours of sleep per night do you get on average?    (HOURS)

Do you feel it is?   

Do you dream?     

Do you remember them? 

 

Childhood 

 

What was your favorite toy?

Did you have any collections? If Yes, What?

What were your favorite school subjects?  

 

Personal Reactions to Medicine

  

 

How do you react to Percocet?

 Normal  Strong Reaction Reverse Reaction Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

How do you react to Vicodin?

 Normal  Strong Reaction Reverse Reaction Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

How do you react to Motrin? 

 Normal  Strong Reaction Reverse Reaction Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

How do you react to sleep aids?

 Normal  Strong Reaction Reverse Reaction Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

How do you react to birth control?

 Normal  Strong Reaction Reverse Reaction Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

How do you react to Anti-Biotics?

 Normal  Strong Reaction Reverse Reaction __parser__boolean_attribute_value__parser__ Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

How do you react to RhoGAM?

 Normal  Strong Reaction Reverse Reaction Doesn't Work   Allergic   Get a Yeast Infection

 Mouth Soars or Swelling Side Effects Bowel Issues OTHER Never Used it

 

 

Family History including Self

 

Rheumatic Fever?   

Black Plague Survivors?  

Rh-Negative Factor?  

Delta 32 Mutation?  

HLA-B27 Positive?  

Ankylosing Spondylitis?  

Spondyloarthropathy Issues?  

Irriatable Bowel Syndrome? '

Undiagnosed Pain?  

Auto Immune Issues?  

Crohns Disease?  

Grave's Disease?     

Tyroid Issues?    

Heart Problems?  

Hormonal Issues?  

Premature Hair Greying or Color Loss?  

Asthma?  

No or Missing Wisdom Teeth?  

Cateracts?

Astigmatism?

Genetic Disorder? 

Pink Eye or Conjuctivitis Symptoms/Issues?  

Iron Level Issue?  

Copper Level Issue?  

Blood Issues?  

Rheumatic Issues/Arthritis?  

Achilles Tendon Pain? 

Osteoarthritis?  

Osteoporosis?  

Joint Pain?  

Swelling?  

Insomnia?  

Mental Issues/Lables?  

Bacterial Infections?  

Excessive Natural Cracking of your Bones?  

Kidney Stones?  

Skin Issues?  

Migraines?  

Recurring UTI or Bladder Infection's?  

Diabetes?  

Cancer?   

Autism?

   

 

In Family and/or Personal Pregnancies

 

Trouble Conceiving?   

Blue Baby or Duffy Babies?  

Spontanious Miscarriage?  

Toxemia?  

Early Delivery?

Extreme Water Retension?  

Baby born with/gets Jaundice?  

Ceribral Palsy?  

Twins or Multiple Births?  

Other? Explain....

 

Known Places of Family Origin

 

Your Mother   

Maternal Grandmother 

Maternal Grandfather 

Your Father 

Paternal Grandmother  

Paternal Grandfather 

  

Ethnic Background

 

Your Mother   

Maternal Grandmother 

Maternal Grandfather 

Your Father 

Paternal Grandmother  

Paternal Grandfather 

 

Random

  

Do you feel you have any Genetic Memory or feel drawn towards any specific subject, person, place, etc?        

      If Yes, Please Share....

  

 

Have you ever taken an IQ test? Score?   

Do you get bit by mosquito's?    

Are your a person of faith in a supreme creator/being?    

Do you believe you have a purpose here?    

 

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