VitalWomen Wellness

Full Name

First NameLast Name

What is your date of birth?

What is your gender?

Contact Number

Format: (000) 000-0000.

Email Address

Current weight (in Kg)

Target weight (in Kg) if relevant

Height (in cms)

Reason for Contacting Me

Goal

Average daily calorie consumption (if you count)

Career

Physical activity

How many steps do you take on average per day? (according to an activity tracker or smart phone health tracking app)

Do you follow a specific diet outline (e.g carnivore, vegan, paleo etc?)

Allergen Profile- Do you consume any of the following?

Have you been diagnosed with, experienced, or undergone any of the following:

Liver and Gallbladder - Do any of the following apply?

Adrenal Function - Do any of the following apply?

Serotonin- Do any of the following apply?

Dopamine - Do any of the following apply?

GABA - Do any of the following apply?

Did you train 48 hours prior to doing your recent blood tests?

Upper Gastrointestinal System -(please tick all symptoms that apply)

Have you ever been tested for Helicobacter (H. Pylori)? If yes, was the result negative or positive?

Stool quality reference chart for next question:

Stool- Do any of the following apply?

Small Intestines / Microbiome - Do any of the following apply?

Known food sensitivities or triggers?

Large Intestines / Acetaldehyde - Do any of the following apply?

Candida - Do any of the following apply?

Skin- Do any of the following apply?

Thyroid Function - Do any of the following apply?

Women's Health (women only) - Do any of the following apply?

Blood Sugar - Do any of the following apply?

Environmental Factors- Do any of the following apply?

Do you currently take any prescription medication or natural supplements? If so, what type, what dosages and how long have you taken it for? ( This includes any contraceptive medication).

Please list them.

How often do you consume alcohol?

How many hours of natural light are you exposed to each day?

Disclaimer & Acknowledgment

All information you provide is strictly confidential and will not be shared with any other party.

By signing below, you confirm that the information provided in this questionnaire is true and accurate to the best of your knowledge.

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HEALTH BLUEPRINT