Natural Health Studio Wellness Intake Form (website)

Health & Wellness Intake Form
Full name*

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Health questionnaire

These questions are designed to give me a detailed look into your health and lifestyle, to help me better understand what your body is/ has gone through. This information will be strictly confidential and will help me guide you to give your body what you might be needing. I will give you a plan based on these answers that is just for you.
What is your reason for this visit?
Describe your main symptoms?
How long have you had them?
What treatments have you tried?
Has anything been successful?
Have you or your family recently experienced any major life changes within the last year or since feeling symptoms? Moving, births, deaths, separations, etc. If yes, please comment:
If yes, please provide relevant details.
Have you had time off work/ school/ life in the past year for health reasons?
List any notable medical history such as hospitalisations and surgery:
List all vitamins, minerals, and other nutritional supplements that you are taking now and the brands if you know them:
How often have you taken antibiotics and or oral steroids?
Do your parents or siblings have (or had) any health issues? If so, please explain.
Do you find it hard to lose weight?

YesNo
Do you find it hard to gain weight?

YesNo
Choose the answer that corresponds to your preferred option
What is your current fitness level?

PoorFairFitAthlete
How active are you Currently?

Not at allSomewhatVery ActiveOveractive (don't stop)
Do you exercise regularly? If so, how many times a week?

Never1-3 times a week3-5 times a weekEverydayRandomly
What exercise do you do?

WalkingRunningWeightsHIIT / Bootcamp ? CrossfitYoga / PilatesOther
How do you rate your stress levels ?

Not stressedSometimes stressedAlways stressedStressed out to the max
What best describes your mood?

SteadyUp and downIrritableAnxiousCalmDepressedHappyOther
Tell me about your sleep ?
What time do you go to bed?
Do you find it easy to fall asleep ?

YesNo
Do you wake up at a certain time during the night? (if Yes, what time?)
How do you feel when you wake in the morning?

How Much of these foods do you consume?

	Never	1 x / week	A few times / week	Occassionally	Multiple times / day
Tea / Coffee
Alcohol
Soft Drink
Dairy / milk, cheese, yoghurt
Eggs
Bread
Sugar
Fish / Seafood
Meat
Fruit
Vegetables

Do you follow a particular diet? (Vegan, vegetarian, keto, pescatarian etc)
Do you have any food allergies?
Do you have symptoms after immediately eating such as belching, bloating, tiredness?
If yes, are these symptoms associated with any particular food or supplement(s) that you are aware of?
Do you often skip meals?
Do you snack all day?
Do you believe you overeat?
Do you think you eat enough?
Do you currently (last 3 months) have a food that you have craved or really 'binged' on over a period of time?
Do you experience any of the following

FatigueAutoimmuneHigh blood pressureHeadachesDry skinAcid refluxHigh cholesterolWater retentionHigh blood pressureBrain fogEczemaMuscle / joint painWeight gainHair lossTrouble sleepingBloatingGasLoose stoolConstipationLow moodLow energyIrritable bowel syndromeSkin rashesSugar cravings
Disclaimer

I have read and understand everything on this page. I acknowledge Katie Jamieson is a Natural Integrated Health Practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Katie Jamieson, her lab partners, her independent representatives, associates and aliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.
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Health & Wellness Intake Form

Health questionnaire

Choose the answer that corresponds to your preferred option

Tell me about your sleep ?