Encrypted Application

1:1 Concierge Gut Health Program Application

This health history is an encrypted form.
Full Name*

First NameLast Name
I'm a noun and I love to verb andverb .
What is your age?*
Contact Number*
Email Address*
example@example.com
Gender*
State You Live In*
What is your main health complaint? *
How often does it bother you?
How long has it been going on? *
Has anything brought you some relief?
What have you tried that has not worked?
How does this affect your life, or what does it prevent you from doing?
What additional symptoms are you experiencing? Please take your time and list as many as possible with as much detail.*
Any previous diagnoses (i.e. Type II Diabetes, Hypothyroidism, PCOS, Crohn’s, etc)?*
Any previous surgeries or procedures (i.e. gallbladder removal, chemotherapy, tonsillectomy, etc.)?
Please list any current medications, reason for medication, and any side effects experienced by each medication.*
Please list any past medications, reason for medication, and any side effects experienced by each medication.
Please list any over-the-counter medications currently used on a regular basis (aspirin, Tylenol, ibuprofen, heartburn/GERD medications, topical cortisone cream, etc.). *
Please list any supplements currently used on a regular basis. Please also include why you're taking each and if you notice anything about how you feel on them.
Please list any supplements used in the past and any details about your experience with them (reason for taking, discontinuation, how you felt on them, etc.).
Please describe the type of food you eat (e.g. Standard American Diet, gluten-free, dairy-free, low-carb, Paleo, organic, vegetarian, vegan, eating disorder, etc.).*
Please list any and all relevant historical experiences (e.g., major stressful event (relationship changes count), a major surgery, exposure to chemicals, metals, mold, etc.).*
Please check the conditions that apply to you:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Please check the conditions that apply to your biological family:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Please check any symptoms that you're currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
Do you have any medication allergies?

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Please list any food allergies (not sensitivities, we'll get to those soon):
Please describe your sleep. *
Please describe your movement.
Please describe a typical day for you. What are you doing, during what hours, how do you feel, what do you need, etc?*
Do you have recent (taken in the last ~three months) blood work you can share?

YesNo
Have you completed any of the following tests recently?

OATStool TestingHTMAHormoneFood SensitivityOther
Please list any relevant findings on those tests (including your blood work):
Please check any and all symptoms that you have experienced*

asthmabright light/sunlight bothers mebruise easilycold oftencrave saltdecreased ability to handle colddiarrheadiminished sex drive, low libidodizzy or light-headed upon standingdry skinedema, fluid retention (around ankles, under eyes, etc.)energy lowexcessive facial or body hairexercise exhausts, makes me feel worsefatigue easilyfatigue not relieved by sleepfibrocystic breastshair brittlehair losshay feverheadachesheart arrhythmiaheart palpitationsheartburn, reflux, or GERDhot flashesimpotenceincreased effort to perform daily tasksindigestion when stressed or tenselow blood pressurelow body temperature (below 98 degrees orally)menstrual irregularities/problemsmigrainesnails brittle, break easilynauseaneed daily coffee, tea, or cola (caffeine)night sweatsno energy to exerciseoften awake between 2-3 a.m. (not because I’m hungry)oily skinPMS (cramps, nausea, headaches, irritability, etc.)rashes, dermatitis, itching skin, or hives oftensleepy, drowsy during the dayslow to get going in a.m. and/or like to sleep latesodium retention (medically diagnosed)spider veinsswelling or puffiness under eyestender breaststhin or delicate skintire easily, low stamina/endurancetired/low energy, especially in afternoonunable to get pregnantunable to maintain pregnancyurinate frequentlyuterine fibroidsvaginal drynesswake up feeling tired or unrested
The list continues...*

absentminded frequentlyADD/ADHD experienceangry oftenanxiety, anxiousness (can be for no apparent reason)apatheticavoid emotional confrontations or situationsbest sleep often between 7 – 9 a.m.can’t think clearlyconcentration difficultdecreased ability to handle stress or pressuredecreased tolerance of othersdepression, sadness, melancholydespairemotionally stressedfearful (can be for no apparent reason)feel best in the eveningsfeel overwhelmed oftenfeel unwell oftenfoggy thinkingforgetfulget confused oftenhard to do tasks quicklyhard to get out of bed or get going in a.m.hard to think or act quicklyhave little control over how I spend my timehopelessness feelingsinability to calm downinsomnia - hard to fall asleepinsomnia - wake up & can’t go back to sleepirritabilityjust don’t feel right, not myselflack drive, motivationlearning is difficultless productive than in the pastloud noises bothermemorization difficultmemory poormentally stressedmood swings, emotional ups and downsmust force myself to keep goingnervous breakdownsnervousnesspanic attacksprocrastinate oftenshake or feel nervous under pressuresleeping pills needed for sleepspacey, hard to focusstartle easilystress or pressure causes me to lie down and restsuddenly run out of energytearful, could cry easilythinking gets confused when under pressurethinking not as clearly as in the pastthoughts too many, too rapidtimid, overly cautiousupset easilywork best late at nightworry
Section three...*

arthritis, osteoarthritis, rheumatoidcirculation poordifficulty building musclelosing muscle masslow back painmuscle weaknessosteopeniaosteoporosispain in jaw (TMJ)pain in joints (not due to injury)pain in low back areapain in lower neckpain in sciaticapain in shoulderspain in upper backsprains or strains occur easily or oftenstiffness or achiness, especially in morning
Section four...*

alcohol intoleranceanger, irritability relieved by eatingcraving for sweetsexcessive hungerfeel faint oftenfeel weakhyperglycemia–high blood sugarhypoglycemia–low blood sugarinsulin resistancelight-headed oftennausea, eating relievesoften awake between 2-3 a.m. and need to eat somethingshakiness, nervousness relieved by eating
Section five...

allergies - foodallergies – other inhalantsallergies – seasonal (hay fever)allergies are worsening (severity, frequency, or to more things)bacterial infectionscatch colds easilyCFS-chronic fatigue syndromechemical sensitivitiescoughs or colds usually last for several weeksenvironmentally sensitive, reactivefood intolerances, reactivities, or sensitivitiesfungal infectionsget sick easily or oftengum infections (gingivitis)headachesimmune deficiencyinflammation (not due to injury)often get colds or flupain (not due to injury)parasite infectionssensitive to odors, flowers, or chemicalssick more often, takes longer to get wellsinus problemstooth infections (pyorrhea)urinary tract infectionsviral infections (cmv)viral infections (ebv)viral infections (herpes)yeast infections (candida)
Second to last section*

acnealternating constipation and diarrheaaversion to certain foodsbloatingburping or belchingconstipation (b.m. less than once a day)dark circles under eyesdiarrheaexposure to environmental toxinsheavy metal accumulationintestinal gasirritable bowelkidney disordersleaky gutliver disordersloss of appetitelung disordersoften have nightmaresrashes, hives oftenskin problems, bad skin, bad coloringstrong body odorsweat burns my skin
Last few*

digestive disordersslow healingsweat has an ammonia odorunable to lose weightunintentional weight lossweight gain specifically in waist, hips, thighs
From 1-10 (least-most) how motivated are you to improve your health? Please do not choose 7. *
Over the last few years, what do you estimate you've financially invested trying to solve your health issue(s)? (ex. copays, medications, supplements, courses, programs, labs, time, etc).
Is there anything that might get in the way of you improving your health (family obligations, work hours, financial means, etc)?*
Is there anything that might get in the way of following a personalized nutrition, supplement, and lifestyle health plan?
Do you understand that functional medicine is an investment? Between tests, professional guidance, supplements, and other expenses it can cost between $4-8,000 to get answers and see results.
If accepted, what day next month would you hope your in-take call would be on?

MonthDayYear
Date
Thanks for filling this out. Now the floor is yours — feel free to share anything else you'd like to, ask us anything, make a request, share what makes you most comfortable working with others on your health, etc. If we get to work together, we're here to serve you!
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1:1 Concierge Gut Health Program Application