Lifestyle Docs

Name *

Please, enter your first name followed by last name

Sex *

Male

Female

Date of Birth *

Hypertension/High Blood Pressure

How long have you had Hypertension? *

Less than 1 yr

Less than 5 yrs

Less than 10 yrs

More than 10 years

What is your average blood pressure? *

How often do you check your blood pressure? *

2 or more times per day

Once per day

One or more times a week

One or more times a month

Very seldom on my own

Are you taking any medications for high blood pressure? *

Yes

Please list all medications you are currently taking along with dosage and duration of the medicines. *

Example: medicine/dosage/2 years

How effective are the medicines in controlling your blood pressure?

Work very well

Work most of the time

Not working well

Unsure

Do you experience any side effects from the medications? *

Examples include dizziness/lightheaded, fatigue/low energy, erectile dysfunction, headaches, GI symptoms (diarrhea, constipation, nausea), etc.

What else, besides medicine, are you doing to help lower blood pressure? *

Increased consumption of whole plant foods

Reducing or eliminating coffee and other sources of caffeine, e.g. energy drinks

Reducing your salt intake

Breathing exercises

Exercise regiment

Other forms of stress management

None of the above

Do you experience any of the following? *

Headaches that may be related to high blood pressure

Pounding in chest or ears

Facial flushing

Fatigue

Excessive Sweating

Blurry vision or vision problems

None of the above

Please select all that apply

Why do you think you are experiencing these symptoms?

Do you have kidney disease? *

Yes

If known, please list your last Creatinine level and GFR

Do you have any history of the following *

Heart disease

Myocardial infraction (heart attack)

Stroke

Residual deficits from stroke

None of the above

Do you believe diet and lifestyle can affect your blood pressure?

Yes

Unsure

Health Goals

Please list at least two reasons you would like to get off your medications

Example: Long term financial savings, avoid negative side effects, free up time visiting doctors office, etc

How interested are you in reducing or eliminating you condition using diet and lifestyle? *

Very interested

Interested

Neutral

Not very interested

How confident are you that you will succeed in making diet and lifestyle changes on your own? *

Very confident

Confident

Somewhat confident

Doubtful

How confident are you that you will succeed in making diet and lifestyle changes with support from Lifestyle Docs? *

Very confident

Confident

Somewhat doubtful

Doubtful

Are you open to using water fasting, juicing or a raw diet for short periods of time to support health and healing?

What is the most important change you would like to see by adopting a healthier lifestyle *

Are there any unusual stressors in your life right now that may hinder your efforts to reduce/eliminate your condition(s)?

Readiness today *

I am ready to drastically change my diet and lifestyle to eliminate hypertension and work on other health goals

I am interested in changing my diet and lifestyle but at a slow and sustained pace.

I am interested in changing my diet and lifestyle in the near future

I am interested in changing my diet and lifestyle in the next 6 months

I am not quite ready but see the value in changing my diet and lifestyle.

Available Forms

VI. Detailed Hypertension History Optional

Hypertension/High Blood Pressure

Health Goals