Personal AssessmentName First Last Email AdhesionsDo you experience pain? Yes NoWhere in the body?How Servere? Mild Moderate ServerHave you had a medical diagnosis? Yes NoWhat was the diagnosis?Have you had medical treatment? Yes NoPlease describe:Do you know the cause of the adhesions? Yes NoPlease describe:General HealthDo you have any other underlying health conditions? Yes NoPlease check any that you currently experience: Digestive problems (elimination, bloating, indigestion, acid reflux, etc.) Weight problems (difficulty gaining or losing) Heart or cardiovascular problems/stroke Chronic fatigue Diabetes Hypertension Chronic Immune Deficiency Mental/psychological issues Arthritis Cancer Allergies Yeast infections Frequent colds and/or fluOther Underlying Conditions:Have you had surgery? Yes NoPlease describe when, and what for?Diet/NutritionDo you prepare your own food most of the time? Yes NoDoes someone else in your household prepare your food? Yes NoHow often do you eat at restaurants? Occasionally Often DailyPlease describe your diet: Needs Improvement Generally Healthy Vegetarian Vegan Mostly OrganicDo you wish your diet was better? Yes NoPlease Elaborate:What is your best dietary habit?What is your worst dietary habit?BeveragesDo you drink coffee? No Occasionally Frequently DailyDo you drink alcohol? No Occasionally Frequently DailyHow much pure water do you drink? 1-5 cups/day More than 5 cups/dayPrimary drinking water source: Tap (municipal) Bottled Filtered Spring/WellDo you prefer iced beverages? Yes NoDo you experience food insecurity? Yes NoSupplements/MedicationsDo you take prescribed medications? Yes NoPlease describe what they are for:Do you take over the counter medications? Yes NoPlease describe:Do you take supplements daily? Yes NoPlease describe:Other Health ConcernsIf you have other concerns not covered by these questions, please describe: