Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Email Address
*
Overall, how is your health
When was the last time you felt well? Have there been any events that triggered changes in your health? What are your specific challenges?
Birth History
Check all that apply.
Childhood Health
Check all that apply.
Emotional Wellbeing
Please list any diagnosed medical conditions.
This is a way for me to get an idea of your personal health journey.
What is your daily stress level?
I am barely getting by
Some days are ok, others I feel stressed
I handle stress well
How often do you move your bowels?
Daily/Around the same time each day
Not necessarily daily/Constipated
Diarrhea/More than once per day
Do you have:
Microbiome Risk Factors
Check any that apply.
Techniques for Mental Health: Do you see a therapist? Do you feel that you have social support? Do you have close trusting relationships?
For Women: Do you have
Regular cycles
Irregular cycles
Heavy periods
Anemia
Adverse reactions to birth control
If you're sexually active, what kind of birth control do you use?
Check any that apply.
How often do you exercise?
Never
Rarely
Frequently, a couple times per week
Daily, I enjoy exercise
Forms of exercise, etc.
Check any that apply.
Have you ever been diagnosed with any of the following?
Do you have a family history of any health conditions?
Vitamin Deficiency: Magnesium
Do you have any of the following symptoms? Check all that apply.
B12
Iron
Folate
Vitamin D