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ONLINE CONSULTATION

IN THREE EASY STEPS

STEP 1: Complete the Health Questionnaire below

STEP 2: Remit consultation fee of US$60.00 via credit card or PayPal

STEP 3: We will contact you via email to set-up a 30 minute consultation

(either by telephone or online if you reside outside of North America)

http://www.PayPal.com account healthman@sbcglobal.net.

John Dandridge, CNC, Online Consultations

1820 E. 2nd. St., Cleburne, TX. 76031.

Our $60.00 Initial Consultation Fee provides:

30 minutes of questionnaire analysis before our phone meeting.

30 minutes of private phone consultation.

30 minute Follow Up phone conversations are available

for an additional US$30 per call/30 minutes.

Health Questionnaire

ALL INFORMATION IS

PRIVATE AND CONFIDENTIAL

Full Name:

Mailing Address:

Daytime Phone#: Evening Phone#:

Age: Height: (inches) Weight: (lbs)

Male Female

Married Single Divorced

Ethnicity:

Blood Type:

PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AS POSSIBLE

1. The primary ailment or sickness that you are concerned with.

1. 1 The Medical diagnosis by your medical doctor.

2. Have you ever undergone major surgery? If so, please list.

3. Please list any major injuries that you have suffered in your lifetime. (broken bones, car wrecks, etc.)

4. Do you suffer from any of the following? Please check as many as apply.

Headache Fatigue Muscle Pains Joint Pains Indigestion Tremors Constipation Dizziness Poor Coordination Depression Mental Confusion Mental Illness Tingling in hands Tingling in feet Arthritis Abnormal Nerve Reflexes Back Pain Allergy Symptoms

Recurrent Respiratory Problems Insomnia Mood Changes Food Allergies Hemorrhoids Sinus Congestion Acne Ulcers Psoriasis Asthma

5. What are your particular eating habits?

Example of a typical breakfast?

Example of a typical snack before lunch? (if you don't snack at this time please say NO)

Example of a typical lunch?

Example of a typical snack before supper? (if you don't snack at this time please say NO)

Example of a typical supper?

Example of a typical snack after supper? (if you don't snack at this time please say NO)

Example of a typical snack before you go to bed? (if you don't snack at this time please say NO)

Anything else to say regarding eating habits?

6. Do you drink caffeinated drinks? YES NO How many cups per day?

What other types of beverages do you drink?

7. Do you drink sodas? YES NO How many per day?

What type? Diet Decaf Regular

8. Do you smoke or use other tobacco product?___ If yes, how long?___ Have you ever smoked or used other tobacco products?____ If yes, when and how long?_______.

9. Do you take prescription medication or vitamins or other supplements? Please give the name(s) of each.

This next section for WOMEN ONLY. If you are male please go to Question 19.

10. Have you used birth control pills or injections (Depo-Provera)? YES NO For how long?

10. 1. Did you have any noticeable adverse effects?YES NO If yes, what kind?

11. Are you taking hormone replacement therapy? YES NO

12. Do you or have you suffered from PMS? YES NO

13. Would you describe yourself as having normal menstruations? YES NO

How many days does your period last? days. Please check as many as apply:

Normal bleeding Excessive bleeding Pain Cramps Bloating

Breast swelling Breast tenderness Pimples Acne

14. Do you have Fibrocysts in your breasts? YES NO

14. 1. Have you ever had Fibrocysts in your breasts? YES NO Were/are they painful? YES NO

15. Do you have any history of hormone and/or menstrual cycle problems or irregularities? YES NO

If yes, please explain.

16. Do you have children? YES NO How many?

16. 1 Have you ever breastfed? YES NO How long?

17. What is the age of your youngest child? Oldest child?

18. Are you currently pregnant or trying to get pregnant? YES NO

19. Are you currently trying to lose weight? YES NO

Are you taking a weight-loss product? YES NO If yes, what type?

20. How many times do you exercise each day? How long do you exercise per day? (min)

What kind of exercise?

21. Considering your height, do you think you are:

Massive Very Heavy Heavy Medium Light Very Light

22. How many servings of Tap water do you consume per day? (8 oz. servings)

How many servings of Purified water do you consume per day? (8 oz. servings)

23. How many hours of sleep do you get on average per night?

24. What is your stress level? LOW MEDIUM HIGH

25. What brings you the most difficult stress?

26. What would your family/friends say brings you the most stress?

27. Describe your personality type (i.e., melancholy, aggressive, passive)

28. Are you an optimist or a pessimist?

Any comments:

29. What kind of work are you involved with?

List any job changes in the last 5 years.

30. What is the stress level of your work? High Medium Low

31. What do you do to play?

32. What are your hobbies?

33. Do you have allergies? YES NO Do you have Asthma? YES NO

Do you have any Immune system problems? (do you get sick a lot) YES NO

Comments:

34. Do you regularly have muscular pain or joint pain? YES NO

If yes, how often and what is the severity?

35. Do you have headaches regularly? YES NO

If yes, how often and what is the severity?

36. Has anything in your normal daily routine changed within the past few months? YES NO

If yes, how?

37. Have you had an extreme amount of stress in the past 6 months? YES NO

If yes, do you still have this stress and what is the cause?

38. Have you experienced any devastation, emotional breakdown or life changing experience? YES NO

If so, please explain and list your age of each experience. Please be as complete as possible.

39. Do you feel that you have dealt with the above experiences effectively, or have you repressed your emotions and feelings?

40. Do you feel depressed, despondent, disconnected, lack of belonging, general sense of uselessness? YES NO If yes, how often do have these feelings and what do you believe is behind this?

41. Are you able to be yourself in a crowd or around people that you don’t really know? YES NO

Comments:

42. Are you able to laugh at yourself when you do something silly or you make a mistake? YES NO

Comments:

43. Do you have any ambitions or goals that you have not achieved and wish that you could? YES NO

If yes, what has held you back?

44. Are you tired of being sick? Comments:

45. If given proper guidance, do you believe that you have the ability to make positive changes in your life that could help you achieve the level of wellness that you desire?

I have read and agree that the advise and recommendations given to me by John T. Dandridge, III CNC, is not medical diagnosis or medical prescription. I understand and agree that all recommendations are based on what John T. Dandridge III would do as a CNC and through his own personal knowledge base of both experience and research. AGREE DISAGREE

Disclaimer: Specific product recommendations are made only as suggestions based on independent research. These recommendations should not be interpreted as a medical prescription or as a diagnosis. All of the statements and opinions contained in this website have not been evaluated by the FDA and should not be construed as part of any product labeling. This information is not intended to prescribe, diagnose, treat, mitigate, cure or prevent any disease, damage or dysfunction. *Any trademarked names are owned by their respective companies. I have read and agree with this disclaimer. AGREE DISAGREE

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