First and Last Name (required)

Email Address (required)

Address

City

Zip or Postal Code

State or Province

Country

Occupation

Home Phone No. (w/ area code)

Work Phone No. (w/ area code)

Date of Birth (mm/dd/yyyy)

Marital Status

Please describe your main health concern.

Please describe your current emotional state.

Are you taking any medication? If so, please list.

Have you ever had any surgery? Please list type(s) and date(s).

Please describe your digestive system.
Do you feel comfortable after eating?
How often do you have a bowel movement?
What is the consistency of your bowel movements? Have these changed from your past habits?

What is your blood pressure?

What is your cholesterol level?

What time do you go to bed? How long does it take to fall asleep? Do you stay asleep?

How tall are you? What do you weigh? What is your ideal weight?

Do you smoke?
If so, how many per day?

Do you drink alcohol? If so, how much and how often?

Do you practice any form of Meditation?

How did you hear of Dr. Cravatta

For Women Only*:

Please describe your menstrual cycle. (Is it regular, do you experience cramps, PMS, anything else?)
Indicate the date of your last menstrual period.

Have you ever been pregnant? How many times?

Do you have children? If so, what are their ages?

What type(s) of birth control do you currently use?
Also please explain what type(s) of birth control you have used in the past?