Please Fill Out This Asthma Questionnaire
Once we receive this form submission, we will call to set up a FREE 30-minute introductory consultation.
* Full Name:

* Telephone:

* Email Address:

* How long have you been dealing with asthma?

* What medications are you taking?

* How often do you use them?

* Is your asthma worse in the winter than the summer?

* Do you have colds or bronchitis often?

* When was your last cold or bronchitis?

* Do you have a lot of coughing?

* Sinus issues? If Yes how severe.

* When was the last time you took antibiotics?

* Do you have a history of repeated use of antibiotics? (more than 2 a year)

If it's a child- is there a history of ear infections, reflux, or eczema?

Any history of sensitive stomach such as: (check for yes)

* Does smoking or perfumes make you feel worse?

* Have you tried any natural healing alternatives in the past?

If yes, what were the results and how long have you tried it?

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