Consultation Questionaire

If you are interested in setting up a phone consultation with Dr. Hoban, please contact 818-348-1020.
Please fill out the following questionnaire prior to your consultation. Dr Hoban will review this free of charge as well as recommend any supplements that may be beneficial for you as well. We currently have a special for anyone who has had a consultation, when purchasing any Health Linx Supplement product the 4th bottle is free.

Today's Date:

Your Full Name (required field):

Your Email Address (required field):

Your Address:

Telephone:
Home -

Cell -

Your Date of Birth:

Are you Male or Female?
MaleFemale

Your Height:

Your Weight:

Your Blood Type:
ABABO

Your Occupation:

Your Marital Status
SingleMarriedSeperatedDivorcedWidowed

Condtions and/or Symptoms

Are you currently taking any prescription or over the counter medications? If Yes, please list:
YesNo

Are you taking any vitamins and/or supplements? If Yes, please list:
YesNo

Do you have any allergies? If Yes, please list:
YesNo

Blood Pressure:
LowNormalHigh

Cholesterol:
LowNormalHigh

Stress:
LowNormalHigh

Energy:
PoorFairGood

Sleep:
PoorFairGood

Focus:
PoorFairGood

Memory:
PoorFairGood

Thyroid:
Under-ActiveNormalOver-Active

Do you have any cold extremities? If Yes, please list:
YesNo

Do you presently, or have you ever had an ulcer? If Yes, please explain:
YesNo

Immediately After Eating, do you experience any of the following? (Check all that apply)

Two hours after eating, do you experience any of the following? (Check all that apply)

Bowel Movement

History of Antibiotic use

Do you excersize? If Yes, please list how many times a week and what types of exercise:
YesNo

Do your fingernails show the following? (Check all that apply):

Are you experiencing Hairloss?

YesNo

How's your weight?

UnderNormalOver

If overweight, which parts of the body?

How's your skin?

DryNormalOily

How many glasses of water do you consume daily?

Please check your answers regarding your consumption of the following:

Coffee NoLowMediumHigh
Alcohol NoLowMediumHigh
Black Tea NoLowMediumHigh
Dairy NoLowMediumHigh
Diet Colas NoLowMediumHigh
Colas NoLowMediumHigh
Junk Food NoLowMediumHigh
Fast Food NoLowMediumHigh
Fried Food NoLowMediumHigh
Cigarettes NoLowMediumHigh
Narcotic Drugs NoLowMediumHigh
Vegetables NoLowMediumHigh
Meat NoLowMediumHigh
Fruits NoLowMediumHigh
Sweets NoLowMediumHigh



The following section is applicable to women only
Please circle one of the following:

Menstruating? MenopausalPregnantNursing

If menstruating? RegularIrregular

Do you experience PMS? YesNo

If menopausal, do you experience hot flashes?

YesNo

Osteoporosis?

YesNo

Mood Swings?

YesNo