Name
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First Name
Last Name
Email
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Phone Number
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Country
(###)
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Date of Birth
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MM
DD
YYYY
Age
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Height
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Current Weight
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Ideal Weight
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Relationship Status
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If you have any diagnosed health problems list the condition(s).
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What are your main health concerns? (Describe in detail, including the severity of the symptoms)
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What treatments have you tried? Have any worked?
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When did you first experience these concerns?
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Do you follow a specific eating style / diet? If so, what and since when?
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What is a typical breakfast?
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Do you eat a lot of greens on a typical daily basis?
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In the past 3 years how many courses of antibiotics have you been on?
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How often did you take antibiotics as a child/teen?
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List any medicine you are currently taking
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List all vitamins, minerals, herbs and nutritional supplements you are currently taking
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How many caffeinated beverages do you consume a day?
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How many times a week do you consume alcohol?
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Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom.
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Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? If so, please explain.
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Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain.
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Do you have any known food allergies or sensitivities?
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On average, how much water do you drink a day?
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Is there anything else I should know about your current diet, history or relationship to food?
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On average, how many hours of sleep do you get a night? What time do you go to bed?
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How long does it usually take you to fall asleep once in bed?
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Do you have issues staying asleep through the night?
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How would you rate your energy levels when you wake up in the mornings?
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Do you use any electronic devices whilst in bed? Phone, laptop etc.
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On a scale of 1-10 what would you rate your general level of anxiety/stress?
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How stressful do you consider your job?
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Are there any other things that cause you notable stress?
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Are there any things you believe you use to distract yourself from, or to conceal your anxiety and stress?
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How much time on average, do you spend scrolling on social media?
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How often do you feel negative emotions arise out of nowhere?
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If there are any, please list any habits you've been wanting to cut out.
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Bowel Movement Frequency:
Bowel Movement Consistency:
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
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How many times a week do you exercise/move with some intensity?
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Which kind(s) of exercise/movement do you do and for how long?
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What is your activity level at your job?
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Are you a current cigarette smoker? If so, how many per day?
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How much time would you be willing to allocate yourself for a morning routine?
How much time would you be willing to allocate yourself for an evening routine?
On a scale of 1 - 10, please rate your readiness to change.
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How are/were your menses? Do/did you have PMS? Painful periods: If so, explain.
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In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?
Have you experienced any yeast infections or urinary tract infections? Are they regular?
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Have you/do you still take birth control pills: If so, please list length of time and type.
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Have you had any problems with conception or pregnancy?
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Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here.
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