Name * First Name Last Name Email * Date of Birth Age * What is your occupation? * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Contact Method * Phone Text Email Mail Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Relationship * HEALTH & WELLNESS GOALS * What are your health and wellness goals? Why are they important to you? PERSONAL HEALTH & FAMILY HISTORY * What's the most important thing you'd like to share about your family history? Who is your primary care provider? * Have you seen other physicians or specialists? If so, list them. * Please list any supplements or medications you take. * Have you experienced any barriers or challenges to accessing healthcare? * YES NO What medical diagnoses or conditions do you have? * List serious illnesses, hospitalizations, injuries, or surgeries. * Describe the health of your Mother and Father * Is there anything from your childhood pertaining to health you'd like to mention? * Do you have any other notable family or personal health information you'd like to share? * What is your current height and weight? * How many hours of sleep per night on average? * How would you describe your quality of sleep? * How is your energy level most days? * VERY LOW Strongly Disagree Disagree Neutral Agree Strongly Agree VERY HIGH Strongly Disagree Disagree Neutral Agree Strongly Agree Do you experience pain, stiffness, or swelling on a regular basis? If so, please explain. * Do you have any METABOLIC HEALTH concerns? Blood Sugar Imbalances Elevated Cholesterol Elevated Blood Pressure Elevated Triglycerides Other None Do you have any DIGESTIVE HEALTH concerns? Bloating Constipation Diarrhea Gas Nausea Stomach Pain Other None How many bowel movements (on average) do you have per day? * Do you have any REPRODUCTIVE HEALTH concerns? * Infertility Irregular Menstrual Cycle Low Libido Other None Do you have any HORMONAL HEALTH concerns? * Thyroid Condition Toxin Exposure Signs or symptoms of Hormonal Imbalance None Do you have any IMMUNE HEALTH concerns? * Autoimmune conditions Frequent illness or infection Low Vitamin D levels Allergies and sensitivities Other None Do you have any BRAIN HEALTH concerns? * Brain fog Difficulty concentrating Forgetfullness Other None What foods did you eat growing up? * How would you describe your past relationship with food? Do any specific memories about food or eating come to mind? * Describe your current relationship with food. * What food allergies or sensitivities do you have? * Do you have any of the following? * Challenges with preparing meals Challenges with access to food Difficulties chewing or swallowing food Poor appetite None Do you regularly use any of the following? (Check all that apply) * Alcohol Tobacco Other substances None Do you follow a specific eating approach/practice for personal, health, or religious reasons? * What does a typical BREAKFAST look like for you? * What does a typical LUNCH look like for you? * What does a typical SNACK look like for you? * What does a typical DINNER look like for you? * What, if anything, would you change about your nutrition? * How would you describe your overall mental and emotional health? * How do you like to support your mental health? * How do you cope with stress? * How often do you experience _____? NOTE: 1 = NEVER and 5 = ALWAYS * ANGER Strongly Disagree Disagree Neutral Agree Strongly Agree EXCITEMENT Strongly Disagree Disagree Neutral Agree Strongly Agree FEAR Strongly Disagree Disagree Neutral Agree Strongly Agree JOY Strongly Disagree Disagree Neutral Agree Strongly Agree LOVE Strongly Disagree Disagree Neutral Agree Strongly Agree SADNESS Strongly Disagree Disagree Neutral Agree Strongly Agree STRESS Strongly Disagree Disagree Neutral Agree Strongly Agree WORRY Strongly Disagree Disagree Neutral Agree Strongly Agree What role does spirituality play in your life? * What are the important relationships in your life? * Is there anything you'd like to share about your social life? If so, explain. * Who do you live with, if anyone? * How many hours per week do you typically work? * What hobbies or recreational activities do you enjoy? * What role does movement and physical activity play in your life? * Is there anything else you'd like to share? BY SUBMITTING YOUR RESPONSES YOU AGREE TO SHARE THIS INFORMATION * YES, I agree this information was knowingly shared Thank you! Please enter all of the requested information.
