*Phone Appointment Paperwork

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Home
About
Go To Store
Appointments
- Book Phone Appointment
EMF Cell Neutralizers
- EMF Demo
Free Tests
Articles
Blog
- Newsletters
- Testimonials

Dr. Valerie Nelson

Board Certified Natural Integrative Doctor

Name*

Email Address*

Reason for appointment*

Phone number (including dashes)*

Birthdate*

Please describe your sleep patterns*

Bowel habits? - normal, constipated, explosive, diarrhea?*

Please describe your stress level*

Please describe your energy level*

Are you in any type of pain? Please describe.*

How many ounces do you drink of the following - water, coffee/tea, alcohol, soda, other?*

Women - please describe menstrual patterns.*

Men - do you have jock itch or athlete's feet*

How many times in your life have you been on antibiotics?*

0-1010-20Over 20

List all medications and why you are taking them.*

What are your top 3 health concerns?*

Do you want me to pray for you during appointment?

YesNoJust on your prayer list

Please check off anything that applies to your health history

• • Alcoholic tendencies• • Allergies• • Anemia• • Anxiety• • Arthritis• • Asthma• • Autism• • Backache• • Bad breath• • Bed wetting• • Bell's Palsy• • Bipolar Disorder• • Blood sugar issues• • Cancer• • Celiac• • Depression Explosive bowels soon after eating• • Diabetes• • Diarrhea• • Digestive Problems• • Disturbed sleep (multiple awakenings)• • Dizziness• • Drooling while sleeping• • Dry skin• • Eczema• • Emphysema• • Endometriosis• • Epilepsy• • Excessive all over weakness• • Excessive body odor• • Excessive saliva• • Fungus-Toenails• • Heart pain• • Heart Problems• • Heavy menstrual bleeding• • Hemorrhoids• • Hepatitis B or C• • Herpes• • High Blood Pressure• • High Cholesterol• • High Triglyceride• • Hives• • Inability to gain weight• • Inability to lose weight• • Indigestion• • Insomnia• • Irregular heartbeat• • Low energy• • Lupus• • Malabsorption syndrome• • Manic Depressive• • Memory problems• • Meniere's Disease• • Menopause• • Menstrual Disorders• • Migraines• • Mood swings• • Mucous in stools• • Muscle pain• • Narcolepsy• • Nausea• • Nerve Twitching• • Rashes• • Respiratory problems• • Restless leg syndrome• • Restlessness• • Rosacea• • Schizophrenia• • Sinusitis• • Skin Problems• • Slow refluxes• • Sudden weight loss• • Teeth grinding at night• • Ulcerative colitis• Acid Reflux (GERD)• All over body odor• Bloody stools• Bone Weaknesses• Bronchitis• Burning sensation in stomach• Chronic constipation• Chronic Fatigue• Chronic Infections• Constant Hunger• Constant Thirst• Crawling sensation under skin (night)• Crohn's Disease• Cysts & Fibroids• Dark circles under eyes• Eye Problems (e.g., Twitching)• Fertility problems• Fibrocystic Breasts• Fibromyalgia• Food allergies• Forgetfulness• Frequent urination• Gallstones• Gas & bloating• Gout• Hair loss• Headaches• Hot Flashes• Irregular menstrual cycles• Irritable bowel syndrome• Itchy anus• Itchy ears• Itchy nose• Itchy skin• Joint pains• Kidney Problems• Kidney Stones• Leaky gut syndrome• Lethargy• Liver Cirrhosis• Long standing obesity• Loss of appetite• Nervousness• Nicotene Addition• Numbness/tingling in hands & feet• Pain in shoulders that radiates down arm• Pain in the navel• Pain in the shoulders• Pains in various parts of the body• Pancreatitis• Parkinson's Disease• Polycystic Ovarian Syndrome• Poor circulation• Poor immune system• Premenstrual syndrome• Prostate problems (enlarged)• Rapid heartbeat• Sudden weight gain• Thyroid Problems• Tinnitus• Unclear thinking• Urinary Tract Problems• Uterine fibroids• Vaginal Dryness• Varicose veins• Vertigo• Warts• Water retention• Yeast infections

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Thank you for contacting us. We will get back to you as soon as possible

Holistic Doctor

Homeopathic Doctor

Abundant Life Wellness

Dr. Valerie Nelson, Board Certified Natural Integrative Doctor

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