The Wilder Way Health Assessment

Health Assessment Form
INSTRUCTIONS

Welcome, wild-hearted friend—

This isn’t just another intake form. This is a chance to pause, reflect, and really tune in to what your body’s been trying to tell you. This Health Assessment is your first step toward a more natural, aligned life—one that honors your unique story and supports you with the right tools, oils, and rituals to feel like YOU again.

A few tips before you begin:
1. Take your time. Find a quiet space where you can focus and get honest with yourself. This is sacred space.
2. Be detailed. Even small things you might overlook can hold powerful insight. The more thorough you are, the more precise I can be in my recommendations.
3. Do your best. If a question feels tricky, answer from the heart. We’ll sort the rest out together.
4. Your info stays safe. Everything you share is confidential and handled with care. Pinky promise.
5. Please allow 30–60 minutes to complete. Once submitted, I’ll review your responses and email your custom guide within 48–72 business hours (maybe longer during busy seasons—but you’ll be updated if that’s the case!).
🔒 Your Privacy Matters
Everything you share in this form is kept completely confidential. Your personal information will never be shared, sold, or used for anything other than creating your personalized wellness plan. This space is sacred—and so is your trust.

Thank you for letting me into this part of your wellness journey. 💛
Let’s get started.
Date

MonthDayYear
Date
Name

First NameLast Name
Age: Date of Birth: Date* Gender: F M
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone: Area Code Phone Number Email: Email
Emergency Contact Name & Best Way to Contact: *
CURRENT HEALTH STATUS

Please provide information on current and ongoing health concerns.

Rows	DATE OF ONSET	SEVERITY/ FREQUENCY	TREATMENT	LEVEL OF SUCCESS

What diagnosis or explanation(s) have been given to you for these concerns?
What physician or other health care provider (alternative or otherwise) have you seen for these concerns?
What makes you feel better?
What makes you feel worse?
If I could wave a magic wand and grant you three wishes, what would they be?
Wish #1
Wish #2
Wish #3
What do you think is at the root of your symptoms/diagnoses?
What do you think your body needs to heal (trust your intuition here)?
When was the last time you felt great?
What else was going on in your life at that time? (Please include information on your diet, workout, physical activity, job, relationships, and any additional details you remember.)
MEDICAL HISTORY
List any Diseases/Diagnosis/Conditions you've had in the past and provide date of onset (mm/yyyy)
HOSPITALIZATIONS / SURGERIES

Please provide a full history of any surgeries or hospitalizations below:

Rows	Date	Surgery / Hospitalization	Treatment Approach	Success?

WOMAN'S HEALTH HISTORY

OBSTETRIC HISTORY

Rows	Answer to the best of your knowledge
Pregnancies (How many?)
Postpartum Depression?
Gestational Diabetes?
Breastfeeding? (If yes, for how long?)

MENSTRUAL HISTORY

Rows	Answer to the best of your knowledge
Age at First Period?
Menses frequency and length?
Pain during menses?
Last Menstrual Period?
Do you use contraception? (if yes, what kind?)
Has Your Period Ever Skipped or have you ever intentionally skipped a period?

WOMAN'S DISORDERS/HORMONAL IMBALANCES

Rows	Yes	NO
Currently, are your periods consistent?
Are you in menopause?

If you are in Menopause, what was the age of onset?

Have you experienced any of these conditions?

Rows	Yes	No
Fibrocystic Breasts
Endometriosis
Fibroids
Painful Periods
Heavy Periods
PMS

Have you experienced any of these symptoms?

Rows	Yes	No
Hot Flashes
Vainal Dryness
Weight Gain
Mood Swings
Decreased Libido
Incontinence
Concentration / Memory Problems
Heavy Bleeding
Palpitations
Joint Pains
Headaches
Cramping

MEN'S HEALTH HISTORY

Have you experienced any of these symptoms?

Rows	Yes	No
Prostate Enlargement
Prostate Infection
Change in Libido
Impotence
Difficulty Obtaining an Erection
Difficulty Maintaining an Erection
Nocturia (Urination at Night)

MEDICATIONS AND SUPPLEMENTS

Current Medications:

Rows	Medication	Dosage	Frequency	Start Date	Reason for Use

Past Medications (within the last 10 years):

Rows	Medication	Dosage	Frequency	Start Date	Reason for Use

Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy):

Rows	Supplement & Brand	Dosage	Frequency	Start Date	Reason for Use

DIGESTIVE HEALTH

Rows	Yes	No
Do you feel like you digest your food well?
Do you feel bloated after meals?

Please complete the following charts as it relates to your bowel movements:
FREQUENCY
COLOR
CONSISTENCY
INTESTINAL GAS
LIFSTYLE HISTORY
SMOKING
Currently Smoking? Yes No How many years?
How many packs per day?
ALCOHOL INTAKE
How many drinks currently per week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits) If "None," skip to the Marijuana and CBD Section.
Does alcohol seem to affect you differently than it does others? If yes, how so?
Do you want to reduce your alcohol consumption? Yes No
MARIJUANA, CBD, AND OTHER SUBSTANCES
Do you currently use marijuana? If so, how much, what form, and how often?
Do you currently use CBD? If so, what dosage, what form, and how often?
What benefits do you notice from using marijuana or CBD?

Are you currently using any recreational drugs? If yes, please specify the drug, dosage and frequency.

Other Substances (Please be thorough and remember, your responses are confidential).
ENVIRONMENTAL & DETOXIFICATION ASSESSMENT
Do you use environmentally friendly household and personal care products?   Yes   No
Do you have known adverse food reactions or sensitivities?   Yes   No
If yes, describe:
Do you eat non-organic produce?   Yes   No
If yes, how many time per week?
Do you eat conventionally raised animal products?   Yes   No
If yes, how many times per week?
Do you consume fast foods or foods with additives or preservatives?   Yes   No
If yes, how many times per week?
Does your current home have carpet?   Yes   No
Have you been exposed to lead paint or treated lumber?   Yes   No
Do you drink filtered/purified/distilled water?   Yes   No
Do you sleep near a Wi-Fi source, cell phone, or laptop?   Yes   No
SYMPTOM TRACKER
For each category below, please indicate frequency of symptoms: 0 = Never, 1 = Rarely, 2 = Moderate (Weekly) and 3 = Severe (Daily)

CATAGORY 1: DIGESTIVE SYSTEM - Stomach

Rows	0	1	2	3
1. Heartburn or acid reflux
2. Excessive burping or bloating
3. Bad breath
4. Burping, bloating, or gas after eating
5. Difficult bowel movements
6. Sense of fullness after meals
7. Undigested food in stool
8. Stomach pain or burning 1-4 hours after meal
9. Feeling relief after antacid use
10. Feel hungry soon after eating
11. Digestive problems vanish after rest
12. Heartburn after eating spicy foods, chocolate, citrus, or caffeine
13. Strong odor from sweat
14. Feel better when not eating
15. Fingernails chip or break easily
16. Stomach pain or cramps in general
17. Diarrhea, chronic
18. Diarrhea, after meals

CATAGORY 2: DIGESTIVE SYSTEM - Intestines

Rows	0	1	2	3
19. Constipation after eating fiber and roughage
20. Feel full 2-4 hours after eating
21. Excess gas
22. Frequent urination
23. Foul-smelling, mucous coated, greasy stool
24. Nausea and/or vomiting
25. Increasing frequency of food reactions/allergies
26. Aches, pains, and swelling in body
27. Frequent bloating and distention after eating
28. Bloating after eating sugar or starches
29. Food allergies
30. Airborne allergies
31. Hives or welts on skin after eating
32. Gluten sensitivity
33. Dairy sensitivity
34. Sinus congestion
35. Craving for pasta and bread
36. Alternating constipation and diarrhea
37. Tend to “zone out” after eating
38. Increased pulse after eating

CATAGORY 3: LIVER & GALLBLADDER

Rows	0	1	2	3
39. High-fat or greasy foods upset stomach
40. Gas and/or bloating several hours after eating
41. Bitter metallic taste in mouth, especially in the morning
42. Fishy-tasting burps after consuming fish oils
43. Difficulty losing weight
44. Eyes have yellowish color
45. Color of stool alternates from normal brown to clay color
46. Skin more red than normal, especially palms
47. Gallbladder attacks or gallstones
48. Excessive hair loss
49. Body swelling for no reason
50. Weight gain
51. Nausea
52. Pain between shoulder blades
53. Age or “liver” spots
54. Motion sickness
55. Headache over eyes
56. Insomnia
57. Sensitivity to perfume, chemicals, etc.
58. Easily intoxicated
59. Pain under rib cage on right side
60. Hemorrhoids or varicose veins

CATAGORY 4: DIGESTIVE SYSTEM - Colon

Rows	0	1	2	3
61. Feeling that bowels do not empty completely
62. Diarrhea
63. Constipation
64. Alternating diarrhea and constipation
65. Stool hard or difficult to pass
66. More than 3 bowel movements per day
67. Use laxatives 3 or more times per week
68. Skip days between bowel movements
69. Cramping in lower abdomen
70. Lower abdominal pain relieved by passing stool or gas
71. Pass large amount of bad-smelling gas
72. Coated or “fuzzy” tongue
73. Loose stools
74. Mucus in stool
75. Blood in stool
76. Anus itches
77. History of parasites
78. IBS or colitis
79. Yeast infections
80. Nail fungus or athletes foot

CATAGORY 5: NUTRIENT DEFICIENCIES

Rows	0	1	2	3
81. Nosebleeds
82. Gums bleed easily
83. Bruise easily
84. Body jerks as falling asleep
85. Heart races
86. Anxiety or persistent worry
87. Small bumps on back of arms
88. Restless leg syndrome
89. Numbness or tingling in body
90. Loss of muscle tone
91. Feeling depressed regularly

CATAGORY 6: ADRENALS

Rows	0	1	2	3
92. Trouble staying asleep
93. Cravings for salt or salty foods
94. Slow getting started in the morning
95. Fatigue in the afternoon
96. Dizziness when standing quickly
97. Headaches in the afternoon
98. Headaches when exercising or exertion
99. Weak nails
100. Difficulty falling asleep
101. Perspire easily even with no activity
102. Under a high amount of stress
103. Gain weight when under stress
104. Wake up tired even after 6 hours or more of sleep
105. Grind teeth or clench jaw
106. Hives
107. Eyes sensitive to bright light
108. Slow to recover from stress

CATAGORY 7: THYROID

Rows	0	1	2	3
109. Flushes easily
110. Feel sluggish or tired mentally
111. Easily fatigued
112. Cold hands and feet
113. Low body temperature
114. Sensitivity to cold
115. Intolerant to heat
116. Require excessive amounts of sleep to properly function
117. Difficulty losing weight
118. Gain weight easily
119. Depression or lack of motivation
120. Seasonal sadness or SAD
121. Morning headaches that vanish as the day goes on
122. Thinning of outer third of eyebrow
123. Hair loss or thinning
124. Fast pulse at rest
125. Nervousness and emotional
126. Insomnia
127. Heart palpitations
128. Night sweats
129. Difficulty gaining weight

CATAGORY 8: BLOOD SUGAR

Rows	0	1	2	3
130. Crave sweet foods
131. Irritable if meals are missed
132. Depend on coffee or sugar to get/stay going
133. Get light-headed or headache if meal is delayed
134. Eating relieves fatigue
135. Feel shaky or weak when hungry
136. Easily agitated or nervous
137. Difficulty remembering things
138. Blurred vision
139. Fatigue after meals
140. Still crave sugar even after eating it
141. Must have sweets after meals
142. Waist girth is equal to or larger than hip girth
143. Frequent urination
144. Increased thirst and appetite
145. Difficulty losing weight

CATAGORY 9: HORMONES - MEN ONLY

Rows	0	1	2	3
146. Difficulty urinating or dribbling urination
147. Pain or burning when urinating
148. Frequent urination
149. Pain on inside of legs or heels
150. Feeling of incomplete bowel emptying
151. Leg twitching at night
152. Decreased libido
153. Decreased number of spontaneous morning erections
154. Difficulty maintaining morning erections
155. Decreased fullness of erections
156. Difficulty or inability to concentrate
157. Depression
158. Muscle soreness
159. Decreased physical stamina
160. Unexplained weight gain
161. Increase in fat distribution around hips and chest
162. Profuse, excessive, uncontrollable sweating
163. More emotional than in the past

CATAGORY 10: HORMONES - MENSTRUATING FEMALES ONLY

Rows	0	1	2	3
164. Length of menstrual cycle varies
165. Menstrual cycle greater than 32 days
166. Menstrual cycle less than 24 days
167. Pain and cramping during menstrual cycle
168. Light blood flow during menstrual cycle
169. Heavy blood flow during menstrual cycle
170. Breast pain and swelling during menstrual cycle
171. Pelvic pain during menstrual cycle
172. Mood swings around and/or during menstrual cycle
173. Irregular menstrual cycles
174. Acne around and/or during menstrual cycle
175. Irritable and/or depressed around and/or during menstrual cycle
176. Acne, in general not just during and around cycle
177. Facial hair growth
178. Hair loss/thinning
179. Yeast infections
180. Endometriosis
181. Uterine fibroids
182. Fibrocystic breasts
183. Vaginal itchiness
184. Vaginal discharge
185. Night sweats
186. Menopausal symptoms
187. Perimenopausal

CATAGORY 11: HORMONES - MENOPAUSAL FEMALES ONLY

Rows	0	1	2	3
188. How many years have you been menopausal? (if greater than 3, just put 3)
189. Since then have you had uterine bleeding?
190. Hot flashes
191. Mental fogginess
192. Not interested in sex
193. Mood swings
194. Depression
195. Painful intercourse
196. Facial hair growth
197. Increased vaginal pain, itching, or dryness
198. Shrinking breasts
199. Acne

CATAGORY 12: IMMUNE SYSTEM

Rows	0	1	2	3
200. Easily catch colds or flu
201. Runny nose or nasal drip
202. Swollen lymph nodes
203. Poor wound healing
204. History of Epstein Barr, Mono, Herpes, Shingles, or Chronic Fatigue

CATAGORY 13: KIDNEY AND BLADDER

Rows	0	1	2	3
205. Pain when urinating
206. Frequent bladder infections
207. Cloudy, dark, or bloody urine
208. Urine has strong odor
209. History of kidney stones
210. Dribbling urination
211. Pain in lower back
212. Frequent urination

CATAGORY 14: ELECTROLYTE AND pH BALANCE

Rows	0	1	2	3
213. Edema and swelling in ankles and wrists
214. Muscle cramps
215. Poor muscle endurance
216. Frequent urination
217. Frequent thirst
218. Craving salt or salty foods
219. Abnormal sweating from minimal activity

NUTRITIONAL LIFESTYLE FACTORS
Height (feet/inches)
Current Weight
Usual Weight +/- 5lbs
Desired Weight Range (+/- 5lbs)

Do you currently follow a special diet or nutritional program?   Yes   No
If yes, please describe:
How many times do you chew your food?
How much fluid do you drink with your meals?
What foods do you dislike?
Do you avoid any particular foods? If yes, what types and why?

If you could only eat a few foods a week, what would they be?

How many ounces of water do you consume daily?

Caffeine Intake - if you consume caffeine, how many:
Coffee Cups / day   1   2-4   >4 per day
Tea Cups / day   1   2-4   >4 per day
Soda Cups / day   1   2-4   >4 per day
MOVEMENT
Do you exercise regularly? Yes No
Current exercise program, if any: (Include type of moevement, number of sessions/week, and duration)
SLEEP AND REST
Average number of hours you sleep per night?
What time do you go to bed?
What time do you wake up?
STRESS
Do you feel you have an excessive amount of stress in your life?
Yes   No
Do you feel you can easily handle the stress in your life?
Yes   No
Do you believe stress is reducing the quality of your life?
Yes   No

What is your #1 stressor currently?
Do you practice meditation or relaxation techniques?
Yes   No
If yes, what types?
Do you participate in activites or have hobbies? If so, please describe the activity ad the frequency.
What are your resources for emotional support (spouse, pets, church, etc.)?
ROLES & RELATIONSHIPS
Please describe your current relationship status:
Name of your partner or spouse (if applicable):
Who is currently living in your household? Names, relationships and ages:

HOW WELL HAVE THINGS BEEN GOING FOR YOU?

Rows	Very Well	Fine	Poorly	Does Not Apply
Overall
At school
In your job
In your social life
With sex
With your significant other
With your children
With your parents

In a typical week, how often do you socialize with friends?
Do you feel that you can depend on your friends?
Yes   No
Are you satisfied with the strength and size of your support system?
Yes   No
Are you satisfied with your current depth and breadth of connections to others?
Yes   No
SPIRITUALITY ASSESSMENT
Do you feel like you matter in the lives of others?   Yes   No
Do you feel your life has meaning and purpose?   Yes   No
Are you a part of a spiritual community?   Yes   No
If so, what is it?
Do you practice self-care and spend time connecting with yourself and your needs?
Yes   No
If so, how often?
Do you regularly spend time in nature?   Yes   No
If so, how often?
Do you feel connected to/grounded in your daily surroundings?   Yes   No
READINESS ASSESSMENT
Rate on a scal of: 5 (Very willing) to 1 (Not Willing)

IN ORDER TO IMPROVE YOUR HEALTH, HOW WILLING ARE YOU TO:

Rows	5	4	3	2	1
Significantly modify your diet
Take nutritional supplements every day
Keep a journal of everything you eat each day
Modify your lifestyle (e.g. work demands, sleep habits, etc.)
Practice relaxation techniques regularly
Engage in regular exercise
Improve your relationships – including the one with yourself

Do you tend to resist change?   Yes   No
What obstacles do you expect to get in the way of you achieving your goals?

Anything else you would like to share?
YOU DID IT!

... and I’m so proud of you. 🥹💛Thank you for taking the time to fill this out with such care and intention. This isn’t easy work—it’s deep, honest, and powerful. But that’s what healing really looks like. Next steps? I’ll be reviewing everything you shared and will be in touch within 48–72 business hours with a personalized wellness plan. That may include essential oils, targeted supplements, holistic rituals, or even book suggestions—tailored just for you and your current needs. Your journey matters. Your wellness matters. And I’m so honored to walk beside you in this season.
DISCLAIMER:

The content in this Health Assessment is designed to support your wellness journey and provide insights based on my training in transformational nutrition, holistic health, and lifestyle coaching.

However, I am not a licensed medical doctor, and the information provided here is not intended to diagnose, treat, cure, or prevent any medical condition.

Always consult your physician or qualified healthcare provider before starting any new supplement, protocol, or significant lifestyle change.

By submitting this form, you understand that this is an educational and supportive tool—not a medical evaluation—and you take full responsibility for your health decisions.
With care and transparency,

CTNC, NLP Master Practitioner & Holistic Wellness Mentor

heatherboers.com
I, your name* have read and understand the above disclaimer. I also acknowledge that while working with Heather Boers and The Wilder Way, I remain responsible for all decisions related to my physical, mental, and spiritual health.
I agree and I'm ready to take radical ownership of my health*
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Health Assessment Form

YOU DID IT!