Health Assessment

Functional Health Assessment

Please complete this form prior to our Zoom consultation.

Name

First NameLast 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:

UPPER GASTROINTESTINAL SYSTEM (please tick all symptoms that apply)

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)

LARGE INTESTINES / ACETALDEHYDE (please tick all symptoms that apply)

LIVER AND GALLBLADDER (please tick all symptoms that apply)

ADRENAL FUNCTION (please tick all symptoms that apply)

THYROID FUNCTION (please tick all symptoms that apply)

BLOOD SUGAR (please tick all symptoms that apply)

WOMEN'S HEALTH (women only) (please tick all symptoms that apply)

Please describe your cycle including cycle length, duration of bleed, heaviness of bleed, and any other information relevant to your cycle.

SEROTONIN

DOPAMINE

GABA

ENVIRONMENTAL FACTORS

Have you had the COVID Vaccines?

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.