Additional Medical Information Brief responses will expedite your treatment Information Please complete these 10 questions. Date* MM slash DD slash YYYY Name* First Last 1. Do you suffer from frequent infections, now or as a child? yes no If yes, please provide details.2. Do you suffer from allergies or asthma, now or as a child? yes no If yes, please provide details3. Have you had a tonsillectomy or appendectomy? yes no If yes, when? MM slash DD slash YYYY 4. Have you taken antibiotics frequently? yes no If yes, for what and when.5. Do you have amalgam fillings? Dental extractions? Root canals? yes no 6. Do you suspect food allergies/intolerances/sensitivities? yes no If yes, please provide details7. Do you suffer excess gas production or bowel irregularity? yes no If yes, please provide details8. What sources of water do you drink? Select All tap bottled filtered 9. What is your average weekly alcohol consumption?Beernumber of bottlesWineouncesHard LiquorouncesHard Ciderounces10. Do you use cannabis products? yes no If yes, what type?What do you suspect are the main reasons causing your health problems?
