HARRIS INTEGRATED HEALTH AND NUTRITION
Welcome
Meet Dr. Harris
Do You Feel Lucky
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Digestive and Lifestyle Symptoms Assessment
Digestive Health Appraisal Questionairre
Female Hormone Self Assessment
Male Hormone Self Assessment
Medical Symptoms Questionaire
Nutritional Assessment
Gluten Sensitivity Assessment
Dairy Sensitivity
Toxin Exposure Assessment
Toxic Burden
Clinical Clues of Low Stomach Acid
Leaky Gut/Intestinal Permeability
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Candida Assessment
Causes of Leaky Gut Syndrome
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Health History
Please Fill Out Form as Best You Can and Submit it by Clicking the Button Below
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Name
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First
Last
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Occupation
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Phone Number
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Height
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Weight
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Marital Status
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Single
Partner
Married
Seperated
Divorced
Widow(er)
Number of Children
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Today's Date
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Email
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Date of Birth
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Gender
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Male
Female
Check Box
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Debilitating Fatigue
Depression
Disinterest in Sex
Disinterest in eating
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Shortness of Breath
Panic Attacks
Headaches
Dizziness
Check Box
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Insomnia
Nausea
Vomiting
Diahrrhea
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Chronic Pain/Inflammation
Bleeding
Discharge
Itching/Rash
Illnesses, Symptoms
Check all That Apply
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Arthritis
Allergies/Hay ever
Asthma
Alcoholism
Alzheimer's Disease
Autoimmune Disease
High Blood Pressure
Bronchitis
Cancer
Chronic Fatigue Syndrome
Carpal Tunnel Syndrome
Cholesterol (elevated)
Circulatory Issues
Colitis
Dental Issues
Depression
Diabetes
Diverticular Disease
Drug Addiction
Eating Disorder
Epilepsy
Emphysema
Eyes, Ears, Nose, Throat Issues
Environmental Sensitivities
Food Intolerance
Gastroesophageal Reflux (GERD)
Genetic Disorder
Glaucoma
Gout
Heart Disease
Infection (chronic)
Health Habits
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Tobacco
Cigarettes
Cigars
Wine
Liquor
Beer
Coffee
Tea
Soda
Water
Other
Date of Last Physical Exam
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Reason for Consultation
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List of Surgerys
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Check all That Apply
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Inflammatory Bowel Disease
Irritable Bowel Syndrome
Kidney or Bladder Disease
Learning Disabilities
Liver or Gallbladder Disease
Mental Illness
Migraine Headaches
Neurological Issues
Sinus Issues
Stroke
Thyroid Issues
Obesity
Osteoporosis
Pneumonia
Sexually Transmitted Disease
Seasonal Affective Disorder
Skin Problems
Tuberculosis
Ulcer
Urinary Tract Infection
Varicose Veins
Other
Exercise Per Week
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5 -7 Days Per Week
3 - 4 Days Per Week
1 -2 Days Per Week
Exercise (Length)
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45 Plus Minute Workout
30 - 45 Minute Workout
Less Than 30 Minute Workout
Hours of sleep per night
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Time of Day You Feel the Most Energy
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7AM - 9AM
9AM - 11AM
11AM- 1PM
1PM - 3PM
3PM - 5PM
5PM - 7PM
7PM - 9PM
9PM - 11PM
11PM - 1AM
1AM - 3AM
3AM - 5AM
5AM - 7AM
Current Level of Stress
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Low
Medium
High
Time of Day You Feel the Worst
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7AM - 9AM
9AM -11AM
11AM - 1PM
1PM - 3PM
3PM - 5PM
5PM - 7PM
7PM - 9PM
9PM - 11PM
11pm - 1AM
1AM - 3AM
3AM - 5AM
5AM - 7AM
List of Current Health Issues
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Top Causes of Stress
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Would You Like To;
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Have More Energy
Be Stronger
Have More Endurance
Increase Your Sex Drive
Be Thinner
Be More Muscular
Improve Your Complexion
Have Stronger Nails
Have Healthier Hair
Be Less Moody
Be Less Depressed
Be Less Indecisive
Feel More Motivated
Be More Focused
Be More Organized
Think More Clearly
Improve Memory
Not Be Dependent on Over - the - Counter Meds
Be Free of Pain
Sleep Better
Have Agreeable Breath
Have Stronger Teeth
Have Agreeable Body Odor
Get Less Colds
Decrease Allergies
WOMEN
Check all That Apply
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Menstrual Irregularities
Endometriosis
Infertility
Fibrocystic Breasts
Fibroids/Ovarian Cysts
PMS
Breast Cancer
Pelvic Inflammatory Disease
Vaginal Infections
Decreased Sex Drive
STD
C - Section
Surgical Menopause
Menopause
Other
Age of First Period
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Date of Last Gynecoloogical Exam
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Form of Birth Control
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Date of Last Menstrual Cycle
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Interval of Time Between Cycles
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Length of Cycle
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Do You Experience any of these Symptoms Everyday
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Debilitating fatigue
Depression
Disinterest in sex
Disinterest on eating
Shortness of breath
Panic Attacks
Headachs
Dizziness
Insomnia
Nausea
Diarrhea
Constipation
Fecal Incontinence
Urinary Incontinance
Low grade fever
Chronic pain/Inflammation
Bleeding
Discharge
Itching/Rash
MEN
Men Only
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BPH
Prostate (cancer)
Decreased Sex drive
Infertility
Erectile Dysfunction
STD
Other
Submit
Welcome
Meet Dr. Harris
Do You Feel Lucky
Our Philosophy
Professional Affiliations
Paperwork
Health History
Digestive and Lifestyle Symptoms Assessment
Digestive Health Appraisal Questionairre
Female Hormone Self Assessment
Male Hormone Self Assessment
Medical Symptoms Questionaire
Nutritional Assessment
Gluten Sensitivity Assessment
Dairy Sensitivity
Toxin Exposure Assessment
Toxic Burden
Clinical Clues of Low Stomach Acid
Leaky Gut/Intestinal Permeability
>
Candida Assessment
Causes of Leaky Gut Syndrome
Programs
Eye to Eye
>
All Inclusive
Life in the Middle
Pay as You Go
From a Distance
>
All Inclusive
Life in the Middle
Pay as You Go
Diet Lifestyle Environment
Diet
Lifestyle
Environment
Resources
Book; Our Modern Mortal Trilogy
Detox and Meal Replacement
Comprehensive Elimination Diet
Daily/Weekly Physical Activity
Food Diary
>
Daily/Weekly Food Diary
Recipe's
>
Snacks/Appetizers/Soups
Entrees
>
Breakfast
Lunch
Dinner
Salads/Desserts
All Things Coconut
Out of the Box NEK TV
Newsletters
FAQ
A List of Lists
Answers to QUARA
Blog
Power Point Presentations
Cancer
Cancer