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First Name*
Last Name
Gender
Age
Height (Ft/In)
Weight (Lbs)
Email*
Street Address
City
State
Zip Code
Country
Province
Home Phone
Cell Phone
Your Counselor may recommend Glandulars to 'power punch' certain areas. Please select your preference for Glandular recommendations:
Have you used Dr. Morse's Formulas?*
Vitals: Blood Pressure
Eye Color*
Resting Pulse (bpm):
Basal Temp (F):
Urine pH:
Saliva pH:
How Many Bowel Movements do You Have Daily?
Are you taking any medications? Please list individually below:
Are you taking any Herbal Products or Supplements? Please list individually below:
What does your current daily diet consist of? (Please be as honest as possible)
Breakfast
Lunch
Dinner
Snack
What are your primary health concerns?
What do you hope to gain from this program?
Genetic / Family History (Please list all known health concerns for each family member. Leave blank if you aren't sure.)
Mother
Father
Maternal Grandmother
Maternal grandfather
Paternal Grandmother
Paternal grandfather
Sister/Brother
Sister/Brother
Sister/Brother
Sister/Brother
Previous Surgical Procedures (Please list all surgical procedures, minor or major, along with the year)
Do you, or have you ever had difficulty with any of the following? (Please circle all applicable, and indicate: Current, Past, or N/A)
Thyroid/ Glandular System
Cold Hands or Feet
Frequently Cold / Difficulty Warming
Cold, but Burning Inside?
Easy to Gain Weight and Hard to Lose It
Irregular Heart Beat / Arrythmia's (Also Adrenals/Cardiovascular)
Headaches / Migraines
Easily Irritable
Overweight
Low Energy / Always Tired
Goiter
Hashimoto's
Grave's
Reidel's Disease
Family Member with Goiter
Family Member with Hashimoto's
Family Member with Grave's
Family Member with Reidel's Disease
How Much do You Sweat?