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Alternative & Western Therapy
o Nutrition

Laboratory Diagnosis

o Pain
o Allergies / Immune System
o Chronic Fatigue
o Fibromyalgia
o Reproductive Hormones
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o Heavy Metal Poisoning
o Lyme Disease

Blood Sugar Abnormalities (Hyper or Hypoglycemia)

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Questionnaire for Dr. Schwartz to interpret

Before completing this questionnaire, please visit fees & arrangements to submit payment for your personalized evaluation. Dr. Schwartz will not be able to provide comprehensive personalized advice with prior payment.

The following information will be kept in the strictest confidence. We will only use your email address to send your diagnosis and treatment plans. We will never share this information with anyone. For more information, please see our privacy policy.

Please carefully type your email address.

When was the last time you felt healthy?

What medications/supplements are you taking?

What lab tests have been performed? Please give results, if known.

Please list any allergies.

Please list any prior surgeries, trauma, or past diseases.

List all symptoms.

Give a short history of the present problem.

Are all body systems functioning well? If not, please describe.

Please list vaccinations and major prescription drug history.

Please describe a typical 24 hour food intake.

How do you spend your time(work/play)?

What type of exercise do you get?

What is your living situation and how do you enjoy it?

What is the climate system and typical pollutants by you?

Your Age: Sex:  


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These statements have not been evaluated by the Food and Drug Administration.
They are the sole opinion of Dr. Schwartz and are not intented to diagnose, treat, cure or prevent any disease.

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