Fill out form and click on submit to send it to Dr. Barry Taylor. CompanyThis field is for validation purposes and should be left unchanged.Date MM slash DD slash YYYY Name First Last Email GoalsBrainADD/ADHD Yes NO NotesMemory Yes NO NotesConcentration Yes NO NotesConcussions or Injury Yes NO NotesEnergyHow is your energy on a scale of 0-10?ADD/ADHD Yes NO UntitledHearingLoud noises bother Yes No NotesOTM Yes No NotesRinging Yes No NotesVisionNight Vision Yes No NotesBright light bothers Yes No NotesFloaters Yes No NotesPain/burning Itching Yes No NotesCold weather or wind tearing Yes No NotesNoseAllergies Yes No UntitledFrequent Colds Yes No UntitledSneezing Yes No UntitledAM Wake w Mucous Yes No UntitledMouthSore Throats Yes No NotesGums bleed easily Yes No NotesCankers Yes No NotesTeeth/Cavities Yes No NotesTongue coated Yes No NotesLungsDifficult breathing in or out Yes No NotesPhlegm Yes No NotesPain across chest Yes No NotesExercise how often Yes No NotesSmoke Tobacco, Pot Yes No NotesHeartRapid heart beat Yes No NotesWave of energy across chest Yes No NotesKidney/BladderUTIs Yes No NotesFrequency, Urgency, Difficult Urination Yes No NotesJointsNeck Shoulder Elbow, Hands Hips, Knees,Ankles Low Back Yes No NotesStiffness Hyperflexible Yes No NotesMusclesTight, spasms, twitching, soreness Yes No NotesSkinDry, Hives, boils Yes No UntitledBruising Yes No Nails Yes No CirculationHands & Feet get cold easily Yes No NotesDigestionHow often BM? Yes No NotesPain? Bleeding Yes No NotesBloating, Gas, Heartburn Yes No NotesFood cravings Yes No NotesNegative Rxns to Food Yes No NotesSalt, Sugar, Alcohol, Dairy, Meat, Coffee Yes No NotesMenses & HormonesBCP Yes No NotesRegular or Irregular Yes No NotesMiscarriages Yes No NotesAbortions Yes No NotesProcedures Yes No NotesPMS Sugar Craving, Bloating, Breast Tenderness, Mood Yes No NotesVaginal Discharge or abnormal Pap or STD Yes No NotesLibido Yes No NotesDiscomfort w Intercourse Yes No NotesBirth Control used now Yes No NotesLast Pap Yes No NotesNursing Yes No NotesPregnancy Yes No NotesChildbirth Yes No NotesFather present health or died from Yes No NotesMother present health or died from Yes No NotesHealth Patterns in Family Yes No NotesSyblings age & health Yes No NotesMedications Present or Pastmedication Δ
