Functional Health Assessment
Please complete this form prior to our Zoom consultation.
Name
First Name
Last Name
Your Postal Address
Mobile Number (including country code)
Your email Address
Your Date of Birth
Age
Your Weight in KG's
Your Height
Your Occupation
What are your top 3 health goals?
What has stopped you achieving these goals in the past?
Have you been diagnosed with, experienced or undergone any of the following:
Anemia
Anorexia
Abuse or sexual abuse
Anxiety / Depression
Breast Implants
Carpal tunnel syndrome
Chronic Fatigue
Diabetes Type 1
Diabetes Type 2
Endometriosis
Gall Bladder Removed
Graves Disease
Hashimotos
Hiatus Hernia
IBS
IBD
Other Thyroid Conditions
Mental Health Conditions
Polycystic Ovary Syndrome
Root Canal
Seizures
Trigeminal neuralgia
Ulcers (stomach)
UPPER GASTROINTESTINAL SYSTEM (please tick all symptoms that apply)
Belching after eating
Bloating in stomach region
Heartburn or acid reflux
Feel excessively heavy after eating meat
Feel better if you skip meals
Fragile fingernails
Brittle hair / hair loss
Diarrhoea after eating
Undigested food in stools
Frequent use of PPI's, NSAID's or antacids
Aversion to eating meat (not due to ethical reasons)
Discomfort when swallowing tablets
History of H Pylori infection
Bad breath
Frequent Hiccups
Rosacea
Indigestion
Persistant Cough
Esophageal / diaphragm spasm
History of eating disorders
Stomach pain, aching or burning 1-4 hours after eating
Feel hungry within an hour or two of eating
Have you ever been tested for Helicobacter (H. Pylori). If yes, was the result positive or negative?
If positive, what therapy / treatment, if any, did you undergo?
SMALL INTESTINES / MICROBIOME (please tick all symptoms that apply)
Bloating after eating (around belly button region)
Food allergies / sensitivities
Hay fever, congested sinuses or seasonal rashes
Diarrhoea or loose stools
Constipation
History of food poisoning or traveller's bug (even if once off)
History of UTI's
Dry eyes or mouth
Nerve pain
Pins and needles or sleeping limbs
Brittle hair / fingernails
Poor facial skin tone (e.g. looking washed out)
Poor exercise tolerance (e.g. bad muscle soreness)
Joint Pain / Neck Stiffness / Knee Pain / Finger Pain
Tooth or Mouth Sensitivity
LARGE INTESTINES / ACETALDEHYDE (please tick all symptoms that apply)
Coating on your tongue
Bloating lower down (below belly button)
Itchy Inner Ears
Anus or Vaginal itching
Taken more than 5 courses of antibiotics in your life
History of fungal or yeast infections (including athlete's foot)
Jock itch, dermatitis, or fungal rashes
Flakey skin on bottom of feet / heels
Excessively bad smelling gas
Frequently pass gas
Born via caesarean section
Stomach cramps
Itchy Scalp / Dandruff
Anxiety or low motivation
Overly sensitive to alcohol
Lethargy / fatigue
Blood in stool
Sugar Craving
Foul smelling stools
LIVER AND GALLBLADDER (please tick all symptoms that apply)
Pain between shoulder blades
Stomach upset by fatty foods
Loose stools or oily substance in toilet water
Floating stools
Motion sickness
Get easily hungover if you drink alcohol
Sensitive to chemicals / perfumes
Chronic fatigue or lethargy
Gallbladder removed
General itchiness / itchy palms
Feel full for an extended period of time after eating fats
Feel sluggish after consuming fats
Yellow tinge to the whites of the eyes
ADRENAL FUNCTION (please tick all symptoms that apply)
Difficulty falling asleep
Difficulty waking up or getting going in the morning
History of high or low blood pressure
Grinding teeth at night
Chronic back or knee pain
Become dizzy when standing suddenly
Crave salty foods
Emotionally traumatic events in the past
THYROID FUNCTION (please tick all symptoms that apply)
Easily fatigued or sleepy during the day
Difficulty waking up or getting going in the morning
Sensitive to cold temperatures
Constipation
Hair loss or thinning eyebrows
Poor short term memory
Diagnosed with thyroid condition
Consistently low mood
Currently on the birth control pill
Don't use a fluoride water filter for drinking
History of Epstein Barr Virus
BLOOD SUGAR (please tick all symptoms that apply)
Awaken during the night
Crave sweet foods
History of binge eating
Irritable if going long periods between meals
Frequent thirst or urination
Headaches or blurred vision between meals
Shaky between meals
Eating relieves fatigue
Eating causes fatigue
History of diabetes in family
Restless Legs Syndrome
WOMEN'S HEALTH (women only) (please tick all symptoms that apply)
PMS
Crave chocolate around periods
Heavy or painful menstrual flow
Skipped periods
Variation in menstrual cycle length
Painful intercourse
Store most of your body fat around your hips or glutes
Excessive facial or body hair
Hot flashes or night sweats
Acne
History taking birth control
Nickel allergy (including earrings)
Menopausal
Post menopause
C-Section
Please describe your cycle including cycle length, duration of bleed, heaviness of bleed, and any other information relevant to your cycle.
SEROTONIN
Depression
Anxiety
Seasonal depression
Difficulty falling asleep
Highly sensitive to pain
Prone to obsessive behaviours
Loss of enjoyment of hobbies
Social phobia's
DOPAMINE
Depression
Poor concentration or focus
Poor Balance
Low energy
Sleep too much
Tendency towards addictive behaviours
GABA
Anxiety
Insomnia
Panic attacks
Muscle tightness
Use food, alcohol, or tobacco to calm down
ENVIRONMENTAL FACTORS
Do you or close members of your family work with chemicals or petroleum
Do you live next to power lines or industrial plants
Have you lived or worked in buildings with mould
Do you NOT use a water filter for drinking
Is there a Wi-Fi router in your bedroom
Have you had mercury fillings or root canal
Do you NOT stand barefoot outdoors or on cement daily
Do you work night shifts
Have you had the COVID Vaccines?
Yes
No
Please list the type of exercise you do, the frequency, duration and intensity.
Do you currently take any prescription medication? If so, what type, why, what dosages, and how long have you taken it for? (This includes any contraceptive medication).
Please advise any supplements you take and the dosage.
Do you follow a specific diet outline (e.g. Vegetarian, Carnivore, Paleo, etc)
Please advise any food intolerance, sensitivities or triggers.
How many steps do you do per day, on average?
How many hours of natural light are you exposed to each day?
If there's anything further you'd like to elaborate on please add in here.
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