GENERAL INFORMATION SHEET

Name___________________________ Age_____ Today's Date___________

Address_________________________________________________________

City___________________________________ State______ Zip____________

Home Phone__________________ Business Phone______________________

E-Mail Address___________________________Height______ Weight______

Occupation_____________________ How were you referred?_____________

What are your main health concerns or conditions?______________________

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Please list any medications or food supplements you are currently taking: _______________________________________________________________________________

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Please list any recent medical tests results you have, such as blood tests:

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lease list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis._____________________________________________________________________

DIET:

What are examples of typical breakfasts for you? Beverages

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Mid-morning Snacks____________________________________________________________

What are typical lunches for you? Beverages

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Mid-afternoon Snacks___________________________________________________________

What are typical dinners for you?                                                        Beverages

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Evening Snacks________________________________________________________________

How often and what kind of exercise do you do?_________________________

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About how many hours of sleep do you get per day?______________________

I understand that nutritional balancing is a means to reduce stress by identifying and correcting nutritional deficiencies and imbalances. It is not intended as diagnosis or prescription for any disease. I also understand that Dr. Wilson has a medical degree, is not licensed in Arizona and practices as a nutrition consultant.

Signed________________________________Date____________

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SYMPTOM SHEET

Directions: CIRCLE any conditions or symptoms that presently describe you. PLACE A STAR next to the symptoms most important to you.

Joint Pain Joint Stiffness Arthritis, Osteo Arthritis, Rheumatoid Muscle Pain Muscle Weakness Muscle Cramps Bursitis Fractures Osteoporosis Gout Sweet Cravings Sugar Reactions Irritable before meals Can't Skip Meals Hypoglycemia Crave Starches Fat Cravings Other Food Cravings Food Allergies Excessive hunger No hunger Diabetes Rapid Heart Rate Skipped Heart Beats Heart Palpitations Heart Attack Poor Circulation Dizziness Low Blood Pressure High Blood Pressure Angina Arteriosclerosis High Cholesterol______ High Triglycerides____ Cough Bronchitis Asthma Post-nasal Drip Sinus Congestion Allergies Emphysema Fatigue Hypothyroidism Low Body Temperature Cold in Winter/Dry Skin Tend to Gain Weight Hyperthyroidism

Acne Eczema Fungal Infections/Candida Psoriasis Hives Hair Loss Slow Wound Healing Cataracts Glaucoma Meniere's Disease Tooth Decay Excessive Plaque on Teeth Gum Disease Get Infections Easily Epstein-Barr Virus Tumors/Cancer Multiple Sclerosis Parkinson's Disease Scleroderma Anger Anxiety Bipolar Disorder Brain Fog Confusion Depression Irritability Mind Races Mood Swings Obscessive/Compulsive Panic Attacks Poor Memory Schizophrenia Trouble Sleeping Autism Attention Deficit Hyperkinesis Dyslexia Seizures Learning Disability Mental Retardation Delayed Development Bladder Infections Kidney Infections Trouble Urinating Frequent Urination Painful Urination Kidney Stones Water Retention Painful Urination Kidney Stones Water Retention

Sinus Headaches Tension Headaches Migraine Headaches Neuritis Constipation Diarrhea Intestinal Gas Bloating Heartburn Ulcer Stomach Pain Colitis Gall Stones Fissures Hemorrhoids Cirrhosis Diverticulitis Tend to Gain Weight Tend to Lose Weight Anemia Easy Bruising Drug Addiction Alcoholism Smoking WOMEN: Premenstrual Syndrome Water Retention Cramps No Menstruation Heavy periods Light Periods Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocystic Breasts Breast Tumors Yeast Infections Hot Flashes MEN: Prostate Problems Impotence Infertility Other Symptoms or Comments:

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