Health Form | Trevor's Love

Personal Information

First Name Last Name Gender

Male Female

Age Height Weight Email Address Date of Birth Home Address City State Zip Code Home Phone Cell Phone

Preferences & Vitals

Glandular Recommendations

Your Counselor may recommend Glandulars to 'power punch' certain areas. Please select your preference:

Preferred Not Preferred

Dr. Morse's Formulas

Please choose one:

I currently use Dr. Morse's Formulas I used them in the past I have never used them before

Vitals (leave blank if unsure)

Bowel Movements

How many bowel movements do you have daily?

0 1-2 3-4 4 or more

Medications, Supplements & Diet

Medications

Are you taking any medications? Please list individually below:

1.

2.

3.

4.

5.

6.

7.

8.

Herbal Products / Supplements

Are you taking any herbal products or supplements? Please list individually below:

1.

2.

3.

4.

5.

6.

7.

8.

Daily Diet

What does your current daily diet consist of? Please be as honest as possible.

Breakfast Lunch Dinner Snack

Health History & Family

What are your Top 3 Health Concerns? #1 – Primary Concern #2 – Second Concern #3 – Third Concern What do you hope to gain from this program?

Implants

Do you have any implants of any kind? (e.g. Breast Implants, Dental Implants, Joint Replacements, etc.)

Yes No

Previous Surgical Procedures

Please list all surgical procedures, minor or major, along with the year.

Procedure

Year

Procedure

Year

Procedure

Year

Procedure

Year

Procedure

Year

Genetic / Family History

Please list all known health concerns for each family member. Leave blank if unsure.

Mother Father Sister / Brother (1) Sister / Brother (2) Sister / Brother (3) Sister / Brother (4) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Thyroid / Glandular System & Parathyroid

Do you, or have you ever had difficulty with any of the following? Please indicate Current, Past, or N/A. For compound conditions, check all that apply.

Pancreas & Adrenals (Glandular System)

Please indicate Current, Past, or N/A. For compound conditions, check all that apply.

Gastrointestinal Tract & Reproductive Health

Please indicate Current, Past, or N/A. For compound conditions, check all that apply.

Gastrointestinal Tract

Females Only

Males Only

Liver / Gallbladder / Blood · Cardiovascular · Skin

Please indicate Current, Past, or N/A.

Liver / Gallbladder / Blood

Cardiovascular

Skin

Lymphatic System

Please indicate Current, Past, or N/A.

Kidneys, Respiratory & Environmental Exposure

Please indicate Current, Past, or N/A.

Kidneys & Bladder

Respiratory System

Environmental & Other Toxic Exposure

Self-Assessment Health Questionnaire

Questionnaire Submitted!