Name
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First Name
Last Name
Email
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Phone
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Country
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Date Of Birth
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MM
DD
YYYY
Age
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Occupation
Gender
Height
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Weight
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Ideal Weight
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Please provide a list of any diagnosed health conditions you may have
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What are your main health concerns? (include a list of symptoms)
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When did you first notice these issues arising?
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What treatments have you tried? Have any worked?
List any medications 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 often have you taken a course of antibiotics?
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How often have you have taken oral steroids?
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What is your typical daily diet? (Breakfast, Lunch, Dinner, Snacks)
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Are there specific foods that you choose to avoid because of the way they affect you? if so please name the food along with the symptoms you experience
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Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)?
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Do you have any known food allergies or sensitivities?
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How much water do you consume daily?
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How many caffeinated beverages to you consume daily?
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On average, how often do you consume alcoholic beverages per month?
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Are you currently a cigarette smoker? if so how often?
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How many times do you exercise per week?
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What forms of exercise do you practice?
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How long are your workouts?
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How many steps do you average per day?
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How much time are you willing to dedicate to a workout routine?
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Bowel Movement Frequency
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Bowel Movement Consistency
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Do you have intestinal gas? If so, when
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How would you rate your overall Anxiety/Stress level on a scale from 1 to 10?
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How stressful do you consider your job to be?
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Are there any other factors that significantly contribute to your stress levels?
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What strategies have you found effective in reducing your stress levels?
Are there any habits you've been wanting to cut out? If so please list them
How many hours of sleep to you get per night?
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What time do you go to bed?
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Once in bed, how long does it take for you to fall asleep?
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Do you have issues staying asleep throughout the night?
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How would you rate your energy levels upon waking?
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Is/Was your Menstrual Cycle regular?
Do/Did you have painful periods? If so please elaborate
Are you currently taking Birth Control Pills or using a hormonal Intrauterine Device? Please specify type and duration
Have you had any problems with conception or pregnancy?
Have you experienced any Yeast Infections or Urinary Tract infections? If so, are they regular?
