Health + Lifestyle Questionnaire

First name*

Last name*

Gender*

Male

Female

Occupation*

Have you ever experienced...

High Blood Pressure

Heart Trouble

Circulation Trouble

Seizures

Dizzy Spells

Diabetes

Migraines

Other Illnesses

Have you ever had surgery? If yes, please list date, type of procedure, and outcome. *

List any medications you are currently taking.*

List any supplements you are currently taking. *

Do you have any of the following?

Metal anywhere in your body (other than your teeth)?

Do you (or anyone in your family) have a cardiac condition?

Do you have any trouble with your vision?

Do you have any trouble with your hearing?

Are you pregnant?

Do you have any allergies?

Do you smoke? Have you smoked in the past?

Have you ever had any of the following: Physical Therapy, Chiropractic, Massage, Acupuncture, Feldenkrais, Rolfing, Alexander Technique?

Have you ever had any other kind of alternative healing?

Have you had/do you have any injuries or orthopedic problems?

Do you do any regular physical exercise?

If “NO” have you exercised regularly in the past?

If you answered YES to any of the questions above, please expand here:

I am aware that what I am embarking upon is not a quick fix in any way, shape or form, but will require effort on my part in order to achieve my goals. I accept that my involvement is a long-term commitment and I understand that failing to implement any part of my program will reduce my chances of success. I agree to abide by the payment and cancellation policies of Aligned Sovereignty (Please check the box stating that you understand and agree).

The statements made on this website have not been evaluated by the FDA (U.S. Food & Drug Administration).

The information published on this site is not intended to diagnose, treat, cure, or prevent any disease.

The information provided by this website and/or this company is not a substitute for a face-to-face consultation with your physician, and should not be construed as individual medical advice.

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