Health Survey—

Please take a moment to fill out this survey so that Dr. Ladd can provide you the most comprehensive and personalized consultation based on your specific condition (s). None of this information is ever shared or used for marketing purposes. All information provided here is kept confidential and is used to provide you with the most advanced diagnosis and natural remedies available.

Please note: Fields marked with an asterisk (*) must be filled in.

Date: Name: * Phone Number: * Email: * Age: Gender: Occupation: Best Day To Call:* Best Time To Call:* In general would you say your health is: Excellent Very Good Good Fair Poor Aerobic Activity: How would you describe your energy level? Low Up and Down Exhausted Hyperactive Nervous Energy Normal Do you sleep well at night? Yes No Do you have appetite or digestive problems, such as, rapid hungering, poor appetite, bloating, gas, indigestion, or constipation? Yes No Do you get headaches? If so, how often? Yes  No Do you experience any pain or aches in any area of the body? Rate your pain: 10 being the most pain you have ever experienced. - Rate - 0 1 2 3 4 5 1 7 8 9 10 Do you wear glasses? Yes No Are you hard of hearing? Yes No Do you have to clear your throat constantly? Yes No Are you often troubled with spells of sneezing? Yes No Is your nose continually stuffed up? Yes No Do you suffer from a constantly running nose? Yes No Do frequent colds keep you miserable all winter? Yes No Do you get hay fever? Yes No Do you suffer from asthma? Yes No Do you have other allergies? Yes No Has a doctor said your blood pressure is too high/low? Yes No Does your heart often race like mad? Yes No Do ever have difficulty breathing? Yes No Are your ankles often swollen? Yes No Do your muscles or joints constantly feel stiff? Yes No Are you troubled with a serious bodily disability? Yes No Do you have hot or cold spells? Yes No Do you frequently feel faint? Yes No Do you have to get up every night and urinate? Yes No Do you usually get up tired or exhausted in the morning? Yes No Are you: Underweight Normal weight Slightly over weight Very over weight Are you currently taking any medication? Yes No Please take a moment to download and complete the HIPPA and release forms. These forms need to be completed and returned in order for Dr. Ladd to contact and consult with you.  These are federally mandated forms that Dr. Ladd must have on file before she can consult.  Thank you, and we look forward to helping you reach your health goals.