PERSONAL INFORMATION
Full Name
Date of Birth
Age
*
Sex Assigned at Birth
Gender Identity
Preferred Pronouns
Occupation
Email
Phone
Home Address
Preferred Contact Method:
Phone
Text
Email
Mail
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
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HEALTH AND WELLNESS GOALS
What are your health and wellness goals?
Why are these goals important?
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PERSONAL HEALTH AND FAMILY HISTORY
Health Information
What's the most important thing you'd like to share about your health story?
Do you have any of the following? If so, please list:
- Primary care provider:
- Other physicians or specialists:
- Practitioners, therapists, healers, etc.:
Please list any supplements or medications you take:
Have you experienced any barriers or challenges to accessing healthcare?
Medical Information
Do you have any of the following?
- Medical diagnoses or conditions:
- History of serious illnesses, hospitalizations, injuries, or surgeries:
Family History
Describe the health of your:
- Mother:
- Father
Is there anything from your childhood pertaining to your health you’d like to share?
Do you have any other notable family or personal health information you’d like to share?
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PHYSICAL HEALTH INFORMATION
- Current Weight:
- Height:
Sleep Information
How many hours do you sleep per night on average?
How would you describe your quality of sleep?
Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:
How is your energy level most days?
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Do you have any of the following concerns? (Check all that apply.)
Metabolic health
Blood Sugar Imbalances
Elevated Blood Pressure
Elevated Cholesterol
Elevated Triglycerides
Reproductive heath
Infertility
Irregular Menstrual Cycle
Low Libido
Hormonal health
Thyroid Condition
Toxin Exposure
Signs or Symptoms of Hormonal Imbalance (please list
Immune health
Autoimmune Conditions
Frequent illness or infection
Low Vitamin D Level
Allergies and Sensitivities (please list)
How many bowel movements (on average) do you have per day?
Digestive health
Bloating
Constipation
Diarrhea
Gas
Nausea
Stomach Pain
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NUTRITION INFORMATION
What foods did you grow up eating?
How would you describe your past relationship or history with food? Do any specificmemories about food or eating come to mind?
Describe your current relationship with food.
Do you have any food allergies or intolerances? If so, please list:
Do any of the following apply to you? (Check all that apply.)
Challenges with Preparing Meals
Challenges with Access to Food
Difficulties Chewing or Swallowing
Poor Appetite
Do you regularly use any of the following? (Check all that apply.)
Alcohol
Tobacco Products
What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories:
Breakfast
Lunch
Snacks
Dinner
Type a question
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Sadness
MENTAL AND EMOTIONAL HEALTH INFORMATION
How would you describe your overall mental and emotional health?
SPIRITUAL HEALTH INFORMATION
What role does spirituality play in your life, if any?
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LIFESTYLE INFORMATION
Is there anything you’d like to share about your social life? If so, please explain:
How many hours per week do you typically work?
What hobbies or recreational activities do you enjoy?
What role does movement, including sports, exercise, and physical activity, play in your life?
ADDITIONAL COMMENTS
Is there anything else you’d like to share?
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