VitalWomen Wellness

HEALTH BLUEPRINT

OPTIMISING HEALTH AND ENERGY THROUGH BALANCED GUT AND HORMONAL HEALTH
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?)
WheatGlutenDairyOxalatesLectinsNightshadesFODMAPSLegumes, aubergine, tomatoes, peppers, and peasSulfurLeeks, onions, garlic, eggs, and cruciferousvegetables
AnemiaDiabetes Type 2AnorexiaEndometriosisAnxiety / DepressionGall Bladder RemovalBreast ImplantsGraves DiseaseCarpel Tunnel SyndromeHashimotosChronic FatigueHiatus HerniaDiabetes Type 1Other Thyroid ConditionsIBSIBDPolycystic Ovary SyndromeRoot CanalSeizuresTrigeminal NeuralgiaUlcers (stomach)Cancer diagnosis and / or treatment
Pain between shoulder bladesStomach upset by fatty foodsLoose stools or oily substance in toilet waterGet easily hungover if you drink alcoholSensitive to chemicals / perfumesChronie fatigue / lethargyGallbladder removedGeneral itchiness / itchy palmsFeel full after an extended period of time after eating fatsFeel sluggish after eating fats
Difficulty falling asleepDifficulty waking up or getting going in the morningHistory of high or low blood pressureGrinding teeth at nightChronic back or knee painBecome dizzy when standing suddenlyCraving salty foodsEmotionally traumatic events in the past
DepressionAnxietySeasonal depressionDifficulty falling asleepHighly sensitive to painProne to obsessive behavioursLoss of enjoyment of hobbiesSocial phobias
DepressionPoor concentration or focusPoor balanceLow energySleep too muchProne to addictive behaviours
AnxietyInsomniaPanic AttacksMuscle TightnessUse food, alcohol or tobacco to calm down
Did you train 48 hours prior to doing your recent blood tests?
Belching after eatingBloating in stomach regionPass gas shortly after mealsUndigested food in stoolsFragile FingernailsBrittle hair / hair lossBad breathFeel excessively heavy after eating meatAversion to eating meat (not due to ethical reasons)Difficultly digesting meatDiarrhoea after eatingUse of antacids, PPI’s or NSAID’sPreviously diagnosed with H PyloriHeartburn / Acid refluxDifficulty swallowing tabletsAnemia / low iron levelsFrequent hiccupsRosaceaIndigestionPersistent Cough
Have you ever been tested for Helicobacter (H. Pylori)? If yes, was the result negative or positive?
Stool quality reference chart for next question:
1. Constipated: Seperate hard lumps / ‘rabbit droppings’2. Mildly constipated: Lumps compacted together3. Solid:Log with cracks in the surface4.Solid Smooth sausage shaped log5.Soft blobs with clear-cut edges:easy to pass but unsatisfying6.Mushy consistency with ragged-edges and messy to clean7.Liquid consistency with no solid pieces/soft diarrhoea
Bloating after eating (around belly button region)Food allergies / sensitivitiesHayfever / congested sinuses or seasonal rashesDiarrhea or loose stoolsConstipationHistory of food poisoning or travel bug (even if once off)History of UTI'sDry eyes or mouthNerve painPins and needles or sleeping limbsBrittle hair / fingernailsPoor facial skin tone (eg look washed out)Poor exercise tolerance (bad muscle soreness)Joint Pain / Neck Stiffness / Knee Pain / Finger Pain
Known food sensitivities or triggers?
White coating on your tongueBloating down below (below belly button)Itchy Inner EarsAnus or Vaginal ItchingTaken more than 5 courses of antibiotics in your lifeHistory of fungal or yeast infections (includes athletes foot)Jock itch, dermatitis, or fungal rashesFlakey skin on bottom of feet / heelsExcessively bad smelling gasFrequently pass gasStomach crampsItchy scalp / dandruffAnxiety / Low motivationOverly sensitive to alcoholFatigue / lethargyBlood in stoolsSugar cravings
Oral thrushYeast infectionsCrampsWhite patches in the mouth & tongueVaginal itchingNauseaRed spots on tongueCottony feeling in the mouthJock itchDiarrhoeaGasBloatingVision changesUTI’sSkin fungusHeadachesFeel worse after sugarsBrain fogChronic sinusitisToenail fungusAthletes footJoint painLow moodRecurrent herpes outbreaks
Eczema, dermatitis, psoriasisRashesItchingRed toneYellow toneBrown / red tint on shinsRed nodules on tricepsRed, yellow or purple mottling on palmsEasy bruisingThick skin (tough to pinch)DryCracked heels
Easily fatigued or sleepy during the dayDifficulty waking up or getting going in the morningSensitive to cold temperaturesConstipationHair loss or thinning eyebrowsPoor short-term memoryDiagnosed with thyroid conditionConsistently low moodWeakened muscleCurrently on birth-control pillDon't use fluoride water filter for drinkingHistory of Epstein Barr Virus
PMSCrave chocolate around periodsHeavy or painful menstrual flowSkipped periodsVariation in menstrual cycle lengthPainful intercourseStore most of body fat around your hips or glutesExcessive facial hair or body hairAcneHot flashes or night sweatsAcneHistory of taking birth controlNickel allergy (including earrings)
Awaken during the nightCrave sweet foodsHistory of binge eatingIrritable if going long periods between mealsFrequent thirst or urinationHeadache or blurred vision between mealsEating relieves fatigueEating causes fatigueHistory of diabetes in the familyRestless Leg Syndrome
Live next to power lines or industrial paths?Lived or worked in buildings with mouldDo NOT use a water filter when drinkingWIFI router in your bedroomHad mercury fillings?Do NOT stand barefoot outdoors or on cement daily?
YesNo
Please list them.
DailyWeeklyMonthlyOccasionallyNever
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