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?
 Male Female

Your Height:

Your Weight:

Your Blood Type:
 A B AB O

Your Occupation:

Your Marital Status
 Single Married Seperated Divorced Widowed

Condtions and/or Symptoms

Are you currently taking any prescription or over the counter medications? If Yes, please list:
 Yes No

Are you taking any vitamins and/or supplements? If Yes, please list:
 Yes No

Do you have any allergies? If Yes, please list:
 Yes No

Blood Pressure:
 Low Normal High

Cholesterol:
 Low Normal High

Stress:
 Low Normal High

Energy:
 Poor Fair Good

Sleep:
 Poor Fair Good

Focus:
 Poor Fair Good

Memory:
 Poor Fair Good

Thyroid:
 Under-Active Normal Over-Active

Do you have any cold extremities? If Yes, please list:
 Yes No

Do you presently, or have you ever had an ulcer? If Yes, please explain:
 Yes No

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:
 Yes No

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

Are you experiencing Hairloss?

 Yes No

How's your weight?

 Under Normal Over

If overweight, which parts of the body?

How's your skin?

 Dry Normal Oily

How many glasses of water do you consume daily?

Please check your answers regarding your consumption of the following:

Coffee  No Low Medium High
Alcohol  No Low Medium High
Black Tea  No Low Medium High
Dairy  No Low Medium High
Diet Colas  No Low Medium High
Colas  No Low Medium High
Junk Food  No Low Medium High
Fast Food  No Low Medium High
Fried Food  No Low Medium High
Cigarettes  No Low Medium High
Narcotic Drugs  No Low Medium High
Vegetables  No Low Medium High
Meat  No Low Medium High
Fruits  No Low Medium High
Sweets  No Low Medium High



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

Menstruating?  Menopausal Pregnant Nursing

If menstruating?  Regular Irregular

Do you experience PMS?  Yes No

If menopausal, do you experience hot flashes?

 Yes No

Osteoporosis?

 Yes No

Mood Swings?

 Yes No