UNIVERSAL LIFE CONSULTING
Remote Assessment Survey

Please take a few moments to print this form, answer the questions, and return to the address below along with the payment (check or money order for $250.00), a recent "snapshot" style photogaph and the saliva sample.  (Note: Fees for established clients are usually lower, call the office for pricing in your situation) If you are visting this site to simply printout the forms to complete and bring to the office as part of an in office visit, ignore the directions for taking a saliva sample. If available a snapshot photograph for the file would still be appreciated, but is not absolutely necessary.

Collecting the saliva sample

The saliva sample is prepared in the following manner:

1. Obtain a small ZipLoc-style plastic bag. Sandwich and snack bags are ideal, but any clean plastic bag will do.
2. Cut a strip approximately three inches long and a half inch wide from any good quality plain white paper without lines. Ordinary copy or printer paper is best.
3. Moisten the strip with your saliva and place in the plastic bag.  If the bag has a seal, then close it; otherwise, tape the bag shut.
4. Include with the photograph, completed survey and payment. Please wait at least ten working days before contacting our office directly.

PATIENT INFORMATION

Name ___________________________________________________   Date __________________

Street Address ___________________________________________________________________

City, State/Province, Zip ____________________________________________________________

Social Security Number ____________________________________

Home Telephone __________________________________________

Business Telephone _______________________________________

Other Telephone __________________________________________

Email ___________________________________________________

Web site _________________________________________________

Age _______  Height _______  Weight _______   Date of Birth _______________

Sex (check one)  Male _____  Female _____   Blood Type __________________

Marital Status ____________________________

Hobbies/exercise _________________________________________________________________

OCCUPATION INFORMATION

Occupation ______________________________________________________________________

Number of hours worked weekly ______________________

Do you consider your work:  high stress _____   moderate stress _____  low stress _____

DIET

Number of meals per day (circle one)   one  |   two  |  three  |  no schedule

Describe a typical meal:

First meal of day __________________________________________________________________

Second meal _____________________________________________________________________

Third meal _______________________________________________________________________

Snacks _________________________________________________________________________

Are you (circle one)   vegetarian  |   ovo-lacto vegetarian  |  vegan  |  kosher  |   salt-free  ?

Special notes regarding diet _________________________________________________________

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Indicate daily amounts use of:

VITAMIN SUPPLEMENTS

HERBAL PRODUCTS, SINGLE HERBS and COMBINATIONS

HOMEOPATHIC REMEDIES and BIOCHEMIC CELL SALTS

PRESCRIPTION, "OVER THE COUNTER" and RECREATIONAL DRUGS

Have you ever had any form of surgery?

Have you ever had any serious illness requiring a hospital stay or extensive treatment lasting more than a few days?

Do you have any children?  yes   |  no
If so, are they (please check)  your own ___  adopted ___  stepchildren ___  foster ___

Please indicate:

Describe your current complaints and/or symptoms in your own words:

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