A4H Symptom Survey This intuitive and adaptive symptom survey gives us the ability to learn about your health history and health goals so we can better assist you with product recommendations. We look forward to joining you on your health journey! General InformationName(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone(Required)Email(Required) Sex:(Required)MaleFemaleOtherDOB(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height(Required) Weight(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your occupation? Were you referred by anyone? (Please list the source or person who has referred you) Would you like to receive sms/emails about our Product updates and Promotions?YesNoEmergency Contact InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Medical IntakeDiet(Required)VegetarianKetoPescetarianVeganPaleoGluten FreeNo RestrictionsOtherDo you have any known allergies or intolerances? If so, please list below(Required) Your Health Concerns (Please list your health concerns/goals here)(Required) Do you have a confirmed diagnosis? If so, please list below Medical History, including surgeries (Please list any and all health conditions or issues in the past or present)(Required) Family Medical History (Please list any disease or illness in your family) Have you had any organs removed? If so, please list below Medications or Supplements (Please list any medications or supplements you take on a regular basis)(Required) Have you received the Covid Vaccine? If yes, please list the date below Are you on any Anticoagulants?(Required)NoYesIf you answered yes to the previous question, please list them below: Have you had any dental fillings? If so, please list the tooth number and location Have you had any root canals? If so, please list the tooth number and location Toxicity and Symptom ScreeningCheck all boxes that pertain to youDigestive Tract Nausea or Vomiting Diarrhea Constipation Bloating Feeling Belching or Passing Gas Heartburn Intestinal/Stomach Pain Head Headaches Faintness Dizziness Insomnia Mouth/Throat Chronic Coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen, discolored tongue, gums, lips Ears Itchy ears (total) Earaches, ear infections Drainage from ear Ringing in ear, hearing loss Heart Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain Nose Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation Emotions Mood swings Anxiety, fear or nervousness Anger, irritability, or aggressiveness Depression Joints/Muscles Pain or aches in joints Arthiritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness Skin Acne Hives, rashes, or dry skin Hair loss Flushing or hot flashes Excessive sweating Energy/Activity Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness Lungs Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing Weight Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight Eyes Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision Mind Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities Other Frequent illness Frequent or urgent urination Genital itch or discharge DisclaimersI fully understand this is a Symptom Survey designed to provide non-clinical information to a Supplement Specialist(Required) I understand I fully understand the difference between the practice of allopathic (conventional) medicine, nutritional wellness consulting, and Quantum Cellular Scans(Required) I understand I fully understand that any reference to "patient" within this therapy is solely due to technical terminology and in no way implies that the client is a medical patient(Required) I understand I fully understand that the attending technician/supplement specialist does not offer allopathic drugs, surgery, chemical stimulants, radiation therapy, or any other conventional treatments. In addition, he/she does not diagnose, treat, or otherwise prescribe for any disease, condition, or illness(Required) I understand If I desire any services not provided by the attending Quantum Cellular technician/Supplement Specialist, which is my prerogative, I fully understand that I should seek them elsewhere. A referral for such services can be arranged(Required) I understand The Food and Drug Administration has not evaluated these statements. This Symptom Survey is not intended to diagnose, treat, cure or prevent any disease(Required) I understand
