Green Zone Consultation Service

Our goal is to identify and address the root causes of your health concerns, not just the symptoms. By thoroughly understanding your medical history, lifestyle, and health goals, we aim to create a personalized plan to help you achieve optimal well-being. Please take the time to complete this form as accurately and comprehensively as possible. This information will serve as the foundation for your care.

1. Personal Information

Your Name *

Your Gender *

Male
Female

Email *

Phone *

Age Range *

Place of Birth *

Do you live in a city? *

Your Occupation

Hours per week *

Nature of Business

Marital Status *

Single
Married
Divorced
Widowed
Long Term Partnership

2. Health Goals and Current Concerns

What are your primary health concerns? *

What are your top three health goals? *

Do you have any current health problems? *

Your current health problems *

Date of Onset *

Severity/Frequency *

Treatment Approach *

What diagnosis or explanation have you received for these concerns? *

What seems to trigger your symptoms? *

What seems to make you feel better? *

When was the last time you felt well? *

Are there any specific treatments or therapies you are interested in? *

If yes, specify: *

3. Medical History

Illnesses (Check all that apply): *

Anemia
Arthritis
Asthma
Diabetes
Thyroid Disease
Cancer
Digestive Issues
Cardiovascular Disease
Other

Anemia Comments: Anemia Onset:

Arthritis Comments: Arthritis Onset:

Asthma Comments: Asthma Onset:

Diabetes Comments: Diabetes Onset:

Thyroid Disease Comments: Thyroid Disease Onset:

Cancer Comments: Cancer Onset:

Digestive Issues Comments: Digestive Issues Onset:

Cardiovascular Disease Comments: Cardiovascular Disease Onset:

Have you ever been hospitalized or had surgery? *

What was your surgery? *

Surgery Date:

Hospitalization Reason:

Have you had any injuries that are still causing you problems? *

What was your injury? *

Comments

Dental History

Do you have root canals? *

Do you have amalgam fillings? *

Do you have TMJ issues? *

Vaccination History

Have you been vaccinated? *

If yes, specify: *

4. Medications and Supplements

Do you take any medications or supplements? *

Medication/Supplement *

List all medications and supplements

Are you allergic to any medications or supplements? *

If yes, specify: *

How often have you taken antibiotics? *

How often have you taken oral steroids (e.g., Prednisone)? *

5. Lifestyle Information

How would you describe your diet? *

Other, specify: *

Do you eat late at night? *

Do you have any food intolerances? *

If yes, specify: *

Do you experience symptoms after eating? *

If yes, specify foods and symptoms: *

How many meals do you eat daily? *

Do you drink caffeinated beverages? *

How many per day? *

Do you exercise regularly? *

What type of exercise do you do? *

Frequency & Duration *

Intensity

How many hours do you sleep per night? *

Do you experience sleep issues? *

If yes, describe: *

Rate your stress levels: *

Low

Moderate

High

Main sources of stress: *

Do you smoke or use tobacco? *

Type & Frequency *

Do you consume alcohol? *

How often? *

Do you use recreational drugs? *

If yes, type and method: *

6. Environmental Exposure

Are you exposed to environmental toxins? *

If yes, specify: *

Have you been exposed to toxic metals (e.g. mercury, lead)? *

If yes, specify: *

Do you have an air filter at home? *

Do you have an energy tower or WiFi router near your home or workplace? *

How much time do you spend under the sun daily? *

Do you practice any relaxation techniques (e.g., meditation, yoga)? *

If yes, specify: *

Is there anything else you'd like to share about your health or lifestyle?

(Optional)

Please upload any relevant blood test results. (If exists)

Choose file or drag here

Supported format: PDF, DOCX, JPEG, PNG, JPG.

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Thank you so much for your valuable time!

We are excited to be part of your journey toward better health and lasting well-being. Our doctor will carefully review your responses and will soon contact you with personalized recommendations tailored to your needs. We deeply appreciate your trust in us and look forward to supporting you in achieving your health goals and enjoying a more active and vibrant life!

Thank you so much for your valuable time!

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