Questionnaire - Page 9 of 9 Last updated: May 12, 2008

THE ANALYST TM
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The following is confidential information and will not be divulged in any form to any third party.

Unless stated otherwise, all fields are optional.


We need to know where and how to send your report.

Your e-mail address (required field):

Report Format Options
HTML (sample) An HTML report is the same as a web page: readable in any browser on any computer.  About 400-600K in size.
HTML, compressed (sample) A compressed (".zip") report will be a quarter the size of an uncompressed report - about 100-150K.  You will need to have WinZip® (Once completely free, now free to try only) installed on your computer in order to read it.
HTML, compressed, password-protected A password prevents anyone else from reading your report.  You will need to have WinZip® (free) installed on your computer.
Enter your password here:
Adobe PDF (sample) You will need to have the Adobe® Acrobat Reader™ (free) installed on your computer.  Report about 400-600K in size.  This is the preferred format if you are using Windows and Internet Explorer version 5! Versions 4 and 6 work with large HTML files without having hyperlink problems.
Adobe PDF, password-protected A password prevents anyone else from reading your report.
Enter your password here:


Address:
(line 1)
(We may need to contact you. However, your phone number is the most important should problems develop.) (line 2)
  (city/town)
(Using the name / abbreviation of your state, province or English county will help us find any ND's in your area.) (state/province/county)
  (ZIP/postal code)
  (country)

Telephone. Although optional, please include should problems develop where we are unable to get an email to you:
For example: Mailbox is full, mailbox is unavailable, filters are preventing you from getting email, etc..


General Information

How did you find us?
...or by whom were you referred?

Your occupation:

Alternate email address. Occasionally this has been very helpful:
Emergency contact phone. This has rarely been needed:


Medical Information.
Please enter here anything that was not covered adequately in the previous pages.

Your height (required field):
Select feet or meters. Please enter only whole numbers - no fractions or decimals.
:    

Your weight (required field):
Select pounds or kilograms. Whole numbers only please.
   

Your five most significant health problems:
Please list up to 5 problems.
If you are currently seeing an ND or MD in relation to any of these, please provide details.

Past hospitalizations or surgeries:
Please state the approximate year if possible

Your medical history:
Type as much as necessary regarding things that have not been covered yet

Further comments:
...about anything. We are always interested in suggestions or feedback about the web site. Type as much as necessary.