• Date:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender:
  • Status:

  • In  case  of  emergency,  whom  should  we  contact? NameRelationship

  • Image field 33

  • Revelation  Health  2013;  All  Rights  Reserved

  • Please list your current and past health conditions (i.e. Diabetes Mellitus, etc

  • Patient History

  • Mercury

  • Do you have amalgam (silver) fillings in your teeth?
  • Have you ever had an amalgam removed?
  • If you had amalgams removed, was it done by a biological dentist using a safe protocol?
  • Did your mother have amalgam when pregnant with you?
  • Have you ever worked in a dental office?
  • Have you had any dental crowns?
  • Have you had any bridges?
  • Have you had any root canals?
  • Have you had any tooth extractions?
  • Do you have any dental implants, retainers or other metal in your mouth?
  • Did you wear contact lenses during the 1980’s or early 1990’s?
  • Did you take oral contraceptives during the 1980’s or early 1990’s?
  • Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?
  • Have you noticed any adverse reactions to these shots?
  • Do you have any tattoos with red ink?
  • Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

  • Lead

  • Does your occupation involve soldering or metal salvage?
  • Have you done any old home repair or sandblasting?
  • Do you do a lot of painting?
  • Was your home built before 1978?
  • Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)
  • Are you around a lot of fake leather, or vinyl?
  • Do you get stomach aches in the morning?

  • General Toxicity

  • Have you ever lived near, on or by a golf course, freeway or tension wires?
  • Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)
  • Do you have your house sprayed with pesticides for pest control?
  • Do you spray herbicide (weed killers) in or around your home?
  • Do you use conventional insect repellants on your self or family?
  • Do you use conventional sunscreen?
  • Do you use conventional perfume or cologne every day?
  • Do you get your hair colored?
  • Do you use aerosol hairspray?
  • Do you get your nails done?
  • Do you use air freshener in your house, work or car?
  • Do you drink filtered water?
  • Do you drink bottle water if so what kind?
  • Do you have a water filtration system for your entire house or shower filtration?
  • Does your spouse or other family members work around chemicals?
  • Can you think of any other toxic exposures you may have had?

  • Mold

  • Do you see mold growing at home, work or school?
  • Have you ever had water damage at home, work or school?
  • Does your home, workplace or school have a damp or mildew smell?
  • Does spending time in your basement cause or worsen your symptoms?
  • Does your basement ever get wet?
  • Do you have a crawl space?
  • Does your basement or crawl space have a sump pump?
  • Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?
  • Does your car have a mildew smell?
  • Does anyone in your home have asthma like symptoms?
  • Does anyone in your family have chronic sinus infections or irritations?

  • Lyme Disease

  • Have you ever been diagnosed with Lyme Disease?
  • Have you had dry sockets or infected tooth extractions?
  • Do you have small joint pain?
  • Have you ever been bitten by a tick or recluse spider?
  • Have you ever seen a bulls-eye rash appear on any part of your body?
  • Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?
  • Was your mother ever diagnosed with Lyme Disease?
  • Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

  • Health History

  • Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?
  • Does anyone in your family experience similar symptoms to yours?
  • Do you have any history of kidney dysfunction?
  • Do you or any immediate family member have a history with cancer?
  • Do you have any history of heart disease, myocardial infarction (heart attack), etc.?
  • Are you currently having any thoughts of suicide?
  • Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?
  • Do you have a history of strokes?
  • Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?
  • Have you ever been in an auto accident, fallen or received a major physical injury?
  • Are you in menopause?

  • Microbiome Health

  • Do you get foul or sulfur smelling gas (distention, bloating, belching, feeling full and a noisy gut) after eating carbohydrates (ie. grains and vegetables) or fermented foods and/or probiotics?
  • Do you often have gas that has a sulfur or foul smell?
  • Are you sensitive to supplements?
  • Have you ever been vegan or vegetarian for any length of time?
  • Can you tolerate Meat?
  • Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?
  • Have you taken birth control or Hormone replacement therapy for any length of time?
  • If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?
  • Have been on antibiotics for any extended period of time or often as a child or adult?
  • Were you caesarian delivered?
  • Were you breast fed?
  • Does your gut temporarily feel better after a round of antibiotics?

  • Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank.

  • Point Scale

  • 0 = Never had the symptom 1 = Occasionally have it, mild effect

    2 = Occasionally have it, severe effect 3 = Frequently have it, mild effect

    4 = Frequently have it, severe effect

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