Name
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First Name
Last Name
Email
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Phone
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Current Address
Age
Date of Birth
Sex and preferred pronouns
Relationship Status
Children?
Occupation
Please list any health concerns you have and when they began
At what point did you feel your best?
Please list all prescription medication you are currently taking and what they are for
Please list all supplements you are currently taking and what they are for (brands and dosage included)
Have you been hospitalized? If yes, when? Why?
Please list all surgeries you have had
Do you work with any healers, helpers or therapies?
Do you experience any pain, stiffness or swelling?
Heart condition/angina/stroke, heart palpitations/tachycardia, elevated cholesterol, low blood pressure, high blood pressure, tingling arms or legs, weakness or low energy, cold hands and feet, edema (water retention)
Diabetes Type I or II, hypoglycemia, metabolic syndrome, dizzy periods or black outs, sudden weakness and shakiness, experience hunger after eating, irritable if late or missed a meal, wake up at night feeling hungry, frequent weight fluctuations, anorexia/bulimia, binge eating, hypothyroidism, hyperthyroidism, chronic fatigue syndrome
Arthritis, osteoporosis/osteopenia, fibromyalgia, chronic pain, bruise easily, gums bleed/nose bleeds, problems with eyes/glaucoma
Autoimmune disease, frequent colds or infections, antibiotic, cortisone, NSAID use
Asthma, bronchitis, pneumonia, allergies, sinus or ear infections, dry/irritated or itchy eyes
Kidney, bladder problems, infections, swollen or tender glands/lymph nodes
Concentration or memory problems, Parkinson’s, MS, ALS, Seizures, ADD/ADHD, migraines, headaches, restless leg syndrome, mood swings, anxiety/panic attacks, Irritability/nervousness, depression/sadness
Restless sleep/other sleeping problems, sleepiness during the day, insomnia (falling asleep/staying asleep)
Liver or gallbladder problems, nausea/vomiting, ulcers/gastritis, heartburn/reflux/GERD, belching/burping, bad breath, gas, bloating, stomach cramps/abdominal pain, diarrhea, constipation, hemorrhoids, celiac disease, ulcerative colitis, Crohn’s disease, irritable bowel syndrome (IBS), diverticulosis/itis, itchy anus, nose or ears
Melanoma/skin cancer, acne, goosebumps on thighs/back of arms, psoriasis, eczema, dermatitis, fungal infections, itchy skin, loss of hair, nails break, split or peal; white spots on nails
PMS, yeast infections, breast cancer, endometriosis, uterine fibroids, ovarian cysts, cervical dysplasia, hysterectomy
Age of first period
How many days is your cycle on average?
How many days do you have your period for?
Has your period ever skipped? And for how long?
Use of hormonal contraceptives such as birth control pill, patch, nuva ring, IUD? If so, how long?
Please explain if you are currently on a form of birth control or have been in the past
Do you track your cycle?
If so how?
If you have ever been pregnant:
Please elaborate on:
How many times (including pregnancy losses)?
How many births?
If there was pregnancy loss, please explain at what week/month the loss happened and if there were any known causes.
If you have birthed a child:
Please elaborate on:
Vaginal or cesarean birth?
Any perineal tearing?
Feel free to summarize your birth story(s)
If you have reached menopause:
At what age did menopause start?
Did/do you experience:
Hot flashes, mood swings, concentration/memory problems, headaches, weight gain
Pelvic floor screen
Do you experience (or have in the past) any urinary incontinence (leaking), urinary urgency, frequent urination, pelvic floor pain, pain with intercourse, pelvic pain?
How many bowel movements do you have?
What do they usually look like?
How long does it usually take?
How many hours of sleep do you get on average?
Do you wake up at night? Why?
Do you feel rested upon waking?
Do you have a nighttime routine? Please describe
Do you currently follow a specific diet or nutritional program?
If Yes, please describe
Are there foods that you avoid or are allergic to?
Do you crave sugar, coffee, alcohol, cigarettes, or have any major addictions?
Do you grocery shop? If not, who does the shopping?
Do you cook?
What percentage of your meals are home cooked?
Where do you get the rest of your food from?
What is the most important thing you think you should change about your diet to improve your health?
What role does sports and exercise play in your life?
What does your current exercise routine look like?
What is your level of motivation for including exercise in your life? (ie: low, medium, high)
Do you usually sweat when exercising?
What role does stress play in your life?
What do you do to relieve stress and relax?
Have you experienced any emotional or physical trauma in your life that you would like me to know about?
Is there anything else you would like to share?