Health Informational Form

Medical conditions & health concerns (check all that apply):

Anemia

Acid Reflux

Celiac Disease

Diabetes

Dysautonomia (any form)

Food Allergies (list below)

Food Intolerances (list below)

Gastritis

Gastroparesis

Inflammatory Bowel Disease (IBD)

Iron Deficiency

Irritable Bowel Syndrome (IBS)

Kidney Disease (CKD, ADPKD, ARPKD, etc.)

Mast Cell Disorder

Non-Celiac Gluten Sensitivity

Small Intestinal Bacterial Overgrowth (SIBO)

Small Intestinal Fungal Overgrowth (SIFO)

Tick-borne illness (Lyme diesase, babesiosis, bartonella, etc.)

Vitamin & Mineral Deficiencies

Weight management (to gain/to lose)

Other (list below)

Preferred method of consultation:

Telephone (the phone number listed on this form will be used for all consultations)

Telehealth via Google Meet Video (no app needed)

Best day and time for consultations, check all that apply (times are eastern time zone):

Health and Wellness