Comprehensive Health Assessment

Please fill out this form to help me get an accurate understanding of  your health and lifestyle. It's important that you answer the questions as honestly as possible. That way I can identify any health issues you might have, and we can collaborate on finding solutions that work for you.

Name *
Name
Date *
Date
Overall, how is your health
Birth History
Check all that apply.
Childhood Health
Check all that apply.
Emotional Wellbeing
This is a way for me to get an idea of your personal health journey.
Please describe.
Do you have:
Microbiome Risk Factors
Check any that apply.
If you're sexually active, what kind of birth control do you use?
Check any that apply.
Forms of exercise, etc.
Check any that apply.
Have you ever been diagnosed with any of the following?
Vitamin Deficiency: Magnesium
Do you have any of the following symptoms? Check all that apply.
B12
Iron
Folate
Vitamin D