Elements Of Wellness
Hormone Intake Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Birthday
-
Month
-
Day
Year
Date
Age
Occupation and hours per week
Weight and Hight
Blood type
Do you have children? Ages?
Primary complaint?
Secondary complaint?
Tell me about your parents life situation BEFORE you were born, financial status, relationship, important events good and bad
Tell me about your childhood, were your parents together, was your home happy * or chaotic? Were you happy in school, did you get bullied, were you really popular, did you have lots of friends or just a few, Were you a good child or problematic?Do you have happy or bad memories? How were your grades?
Tell me about your teen years, family life and friend life? Did you have an outlet? * Did you do any hobbies or play sports? How was your relationship with your parents? How did you do in school? Did you lose any family members or haveany trauma you haven’t already discussed?
What were your relationships like, family, parents, friends, and siblings as a child, * teen and young adult
What were your relationships like, family, parents, friends, and siblings as a child, * teen and young adult?
Where did you meet your spouse? How long have you been together? Describe * your relationship.
Past Medical History
Asthma
Appendicitis
Arteriosclerosis
Colitis
Depression
Diabetes type 1
Diabetes type 2
Fibromyalgia
Eating disorder
Gallstones
Hepatitis C
HIV
High Cholesterol
Hyper thyroid
High blood pressure
Mono
Paralysis
Mumps
Polio
Physical Abuse
Rheumatic Fever
Scarlet fever
Stroke
Ulcers
Endometreosis
MTHFR Mutation
Anemia
Anxiety
Bronchitis
Epilepsy/seizures
Emphysema
Gout
Goiter
Hepatitis B
heart disease
Herpes Simplex
Hypertension
Heart disease
Low blood pressure
Meningitis
Pace maker
Pneumonia
PTSD
STD's
Uterine Fibroids
PCOS
Amenorrhea
Low or diminished ovarian reserve
Unexplained infertility
Premature Ovarian failure
Age related infertility
Poor Egg quality
Pelvic inflammatory disease
Celiac Disease
Menstrual clots
No menstrual cycle
Ovarian cysts
PMS
Vaginal Sores
Frequent yeast infections
Husbands name/partners name
Male factor fertility
Poor sperm quality
Low sperm count
Sperm morphology
Poor sperm Motility
ED
Varicoecele
Addictions?
Paternal Family Illnesses - Relation-Illness
Maternal Family Illnesses - Relation-Illness
Current medical diagnosis?
Medical Diagnosis -Past - Date of onset
Past hospitalizations/surgeries -Date
Were you born vaginally?
yes
no
Tell me about your MOTHERS pregnancy with you, physical, mental, any medical * issues, trauma, joy, love, etc. Anything that happened during your mothers pregnancy with you. This can be as brief or as specific as you want.
Tell me about your mothers experience being pregnant with you. Did she * experience any personal or medical problems?
Do you know when your mom started cycling?
Do you know how old your mother was when she began developing?
Were you breastfed and if so how long?
Describe your relationship with your mom from an early age till now.
Describe your relationship with your dad from an early age till now
Describe your relationship with your siblings from an early age until now [if applicable]
Who in your family are you closest to and why
Have you taken Antibiotics?
Have you taken birth control
Yes
No
IF yes, how long and when did you stop
Have you been on HRT, BHRT
Yes
No
If yes have you stopped?
Have you done IVF [what was the outcome]
Have you ever had trauma to the head such as car accident, sports injury, etc? * Please explain.
Supplements, dose, frequency, reason for starting?
Are you taking herbs? If so please list dose, frequency start date and reason
Are you on any medications currently? Pleas list dose, frequency and when and why
Do you experience digestive difficulties [bloating, constipation, gas, diarrhea]?
How often do you have a bowel movement
1 or more per day
every other day
every 3-4 days
every 5-7 days
OTHER
What is the color typically
medium brown
very dark or black
Greenish
blood is visible
Yellow, light brown
chalky colored
greasy/shiny
OTHER
Have you ever had food poisoning? If yes, please describe in detail, including 1) * Where were you 2) What did you treat it with and 3) If you feel like you fully recovered from it:
Do you take laxatives
List any known food or environmental allergies and your reaction
Do you avoid this food or environmental triggers when possible
Have you been exposed to any chemicals or toxic metals [lead, mercury, aluminum, arsenic]
What kind of cookware/cooking utensils do you use?
Teflon
stainless steel
copper
glass
Plastic
Aluminum
Cast iron
Other
Have you/do you have mercury amalgams [if they have been removed, when?]
Do you have heart burn or acid reflux?
What kind of fats do you cook with? [butter, olive oil, canola oil, coconut oil, pam etc]
Do scents/odors bother you
FOR WOMEN
If applicable, are you ovulating? and when was the last time
If applicable when in your cycle do you ovulate [what day]
How old were you when your breasts started to develop?
If applicable how long have you been trying to conceive
Please click ALL that apply
Periods are regular every 28-35 days
Periods are sporadic
I am irregular with my cycle
Flow is heavy
Flow is light
Sever cramps
mid cycle bleeding
Have under gone fertility treatments or in cycle now
Have had 1 or more miscarriages
Perimenopausal
Menopausal
I don't cycle
How long is your cycle
When did you start cycling? [How old were you]
How many days does your period last?
Do you clot?
Color of menstruation blood
Can you describe your flow [light to heavy, heavy to light etc]
Breast lumps
yes
No
Cervical mucus
yes
no
What is your PMS, period symptoms like
Date of last period
-
Month
-
Day
Year
Date
If Applicable What phase of your menstrual cycle are you in
Previous live births - Age of mother, age of baby
Premature births
yes
no
IF there is history of miscarriage how far along were you
History of ectopic pregnancy
yes
No
Do you have both your fallopian tubes?
History of HSG [hysterosalpingography]
What was the out come of the HSG procedure
Previous termination of pregnancy? If so week of gestation
Are you regularly exposed to second hand smoke
Are you currently or have you been exposed to mold? (If so, what is/was the * source of the exposure and for how long have you been/were you exposed tomold, if known?)
Men and Women
Have you had your hormones checked within the last sic months? Which ones? Can you provide me a copy of those tests?
Have you had medical blood work done in the last 6 months? If so can you provide me a copy of those tests?
Nutrition
Current diet: BE SPECIFIC. What are you eating for breakfast, lunch and dinner, snacks.
Have you been vegan or vegetarian
Gall bladder removed?
How much caffeine per day [oz]
If you consume alcohol how much per day/week
What other beverages do you drink per day
How many times per week do you consume animal protein
How many vegetables per day and what colours?
How much fruit do you eat per day
Fav foods?
Foods you avoid
Do you consume wheat products?
Dairy products?
Symptoms after eating
Gassy
Bloated
Tired
Feeling over full
Do you experience any of these regularly
Constipation
diarrhea
excessive hunger
little to no appetite
crave sugar
crave salt
Describe your relationship with food. BE SPECIFIC
Meal timing, breakfast, lunch dinner, snacks
In ounces how much water do you drink daily
What type of water
well water
Bottled water
Filtered water
Osmosis water
magnetized water
Water softener?
Hard water?
Daily nourishment
Carnivore
Dairy
vegetarian
vegan
Kosher
Grains
Wheat free
Fried foods
Greens
Spicy
Sweets
bread/pasta/baking
soft drinks
tea
Other
Adrenals, liver, thyroid
On a scale of 1-10. 10 being the highest rate your stress and why
List your main stresses
What makes you nervous or anxious
What makes you feel relaxed
What do you do for fun/What brings you joy
Do you have a faith or spiritual belief [believe in something greater than yourself]
How many hours a day do you use a computer? How many hours a day do you use your cellphone? How many hours per day do you watch TV?
On average how many hours of sleep are you getting per night
Do you have trouble falling asleep?
Do you wake up throughout the night?
Throughout the night do you wake up hungry?
Do you wake up tired or find it hard to get out of bed?
Do you find you are tired throughout the day or seem to crash?
Do you snore
What time do you go to sleep and and what time do you wake up on average
Do you watch tv or use your phone before bed?
Quality of sleep
Normal
Hard time falling and staying asleep
Wake around 3-5 and can't fall back asleep
Easy to fall asleep, but wake easily
Hard time falling asleep
Stay up really late and have a hard time waking up
Energy level from 1-10 throughout the day on average. 10 being the highest
Are you fatigued on a regular basis
Do you include movement in your day that would help maintain your health?
How do you express your creativity?
My body temperature feels
Hot
Cold
Normal
Fluctuates
Is there anything else that this profile did not include that you would like me to be aware of that may be affecting your health that you feel is relevant to this process?
What are 3 goals you have by working with me?
What will having reached your goals do for you
What is life like now for you?
Who else will be affected when you reach your goals?
When we are changing, we ALWAYS end up having to let some things go in order to achieve those goals. What might you "loose" that you value if you were to be successful in your goals?
Trying to conceive. Skip this portion if it does not apply to you
Do you believe you can get pregnant
How do you feel about this
What is the presenting limitation?
How long have you experienced this?
How does this limit you in the rest of your life?
What does it stop you from doing
Describe to me when was the worst time you experienced this problem?
Studies show that past and continued trauma play a significant role in health and * health outcomes. Our understanding of your history will help us to best supportyou moving forward. Have you suffered any trauma in your life? Trauma isanything physical, mental, or emotional that jarred your nervous system. If can be big or small trauma. Please check below.
Death of a family member/loved one
Sexual or physical abuse
Emotional neglect or abuse such as ridicule, bullying, put downs, being ignored or told you were no good by family or a parnter
Life threatening accident or situation [military, or lived in a war zone
Life threatening illness
Physical force or weapon threatened or used against you
Witness the murder, serious injury or assault of another person
Other
If you witnessed or were part of any of the above, please explain
What meaning/reasoning have you attached to this trauma
Do you see a therapist?
Did anyone leave you abruptly as a child? Did you ever feel abandoned
List 3 happy moments as a child
Do you have a close circle of friends? How do you nurture those relationships?
Where did you grow up?
Type a question
Do you have pets? If so can you tell me what they are
Do you smoke? If so how many per day
Have you used or use legal substance? Do you/have you use illegal substance
Dental work done
Fillings
teeth pulled
root canals
Crowns/metal work
Other
Are you vaccinated? Are you up to date [80% of adults are not fully vaccinated because they do not regularly receive their boosters from childhood vaccinations]
Briefly name the vaccinations you have had and approximate dates
Covid 19 and booster vaccinations? Dates?
If you answered no to the previous question do you plan to get it
yes 1
no
Still undecided
Todays date
-
Month
-
Day
Year
Date
Signature In acknowledgement that these are your answers
Save
Submit
Thank you and I am SOOO excited to start working together
Jodi Harty
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