*Health Routine Analysis*
It's time to Take Back Ownership of YOUR Health, one bite at a time!
Full Name
First Name
Last Name
What is your age?
Contact Number
Email Address
example@example.com
What is frustrating you right now about your health?
How are these health challenges currently interfering with your lifestyle?
What are your top 3 health goals / priorities?
Why are these health goals so important to you?
How long have you been thinking about these health goals / making changes?
How often do you feel tired, fatigued, or sluggish, if at all?
Upon waking – dragging to get out of bed!
Throughout the whole day / night
Get the 2-3pm energy crash
Only when not getting the proper amount of restful sleep
Rarely, if at all
Which of these symptoms do you experience frequently, if any?
Anxiety
Depression
Jittery nerves
Irritability
None
Do you have difficulty concentrating or focusing?
Yes
No
How often do you experience bloating, excessive gas, and/or indigestion (especially after meals)?
Daily
Every few days
Once in a while
Never
Do you experience symptoms of:
Irritable Bowel Syndrome (IBS)
Inflammatory Bowel Disease (IBD)
Crohn’s disease
Gastroesophageal reflux disease (GERD)
Gastroenteritis
Colitis
Diverticulitis
Stomach ulcers
Other digestive issue - explain below
If you have a combination of the digestive issues above, or something different, please explain here:
How often do you have a bowel movement?
Once per day
2-3 times per day
Once every other day / every few days
Once per week or less
More than 3 times per day
Which of these do you experience?
Abdominal pain
Abdominal bloating and/or cramping
Dark stools, or blood in the stool
Anal fissures
Anal fistula
Hemorrhoids (internal or external)
Colon polyps
None of the above
How often do you feel dehydrated?
Daily – I can’t seem to get enough H2O!
Every few days
Once in a while
Never
Are you overweight or have difficulty losing weight?
Yes
No
Do you experience frequent headaches?
Yes
No
Do you eat lots of processed foods or fast foods at least 3 times a week?
Yes
No
Which caffeinated products do you consume?
Coffee
Tea
Pop / Diet Pop
Energy drinks (such as Monster, Red Bull, FullThrottle, etc)
Caffeine pill
None
How often do you crave chocolate?
Daily
Every few days
Once in a while
Never
Do you eat refined sugar or artificial sweeteners at least once a day?
Yes
No
Do you crave sweets, bread, or pasta frequently?
Yes
No
How often do you eat animal protein (turkey, chicken, red meat, eggs, dairy, or other animal product)?
Once per day
Twice per day
More than twice per day
Less than once per day
Never
Do you currently take or have taken:
Medications
Antibiotics
Anti-depressants
Birth control
Hormone replacement therapy (HRT)
Vaccinations
A combination of these
Please explain which of the above pills, treatments, shots you're taking / you've taken:
How many hours per night do you sleep?
8 hours or more
Less than 8 hours
Which of these hair, skin, and/or nail issues do you experience:
Dry skin
Brittle or peeling nails
Thinning hair or hair breakage
Eczema or psoriasis
Acne
Rosacea
Melasma
A combination of the above or other skin irritation: please explain below
Please explain the combination of skin irritations or other skin problems you're experiencing:
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Do you feel having support, education, and a safe space is important to you while making changes to your health?
Yes
No
What’s holding you back from making changes (time, finances, support, education, lack of commitment, etc.)?
Is there anything else you'd like to share about your health that wasn't covered above?
What is a realistic budget you can work with right now to truly invest in solutions for your health issues, prevent further disease, and save money in the long run (insurance, doc visits, therapies, medical devices, surgeries, etc.)?
$0 - $500
$500 - $1,500
$1,500 - $4,000
How did we get connected?
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