1:1 Concierge Gut Health Program Application
This health history is an encrypted form.
Full Name
*
First Name
Last Name
I'm a
noun
and I love to
verb
and
verb
.
What is your age?
*
Contact Number
*
Format: (000) 000-0000.
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:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Please check the conditions that apply to your biological family:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Please check any symptoms that you're currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
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?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
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?
Yes
No
Have you completed any of the following tests recently?
OAT
Stool Testing
HTMA
Hormone
Food Sensitivity
Other
Please list any relevant findings on those tests (including your blood work):
Please check any and all symptoms that you have experienced
*
asthma
bright light/sunlight bothers me
bruise easily
cold often
crave salt
decreased ability to handle cold
diarrhea
diminished sex drive, low libido
dizzy or light-headed upon standing
dry skin
edema, fluid retention (around ankles, under eyes, etc.)
energy low
excessive facial or body hair
exercise exhausts, makes me feel worse
fatigue easily
fatigue not relieved by sleep
fibrocystic breasts
hair brittle
hair loss
hay fever
headaches
heart arrhythmia
heart palpitations
heartburn, reflux, or GERD
hot flashes
impotence
increased effort to perform daily tasks
indigestion when stressed or tense
low blood pressure
low body temperature (below 98 degrees orally)
menstrual irregularities/problems
migraines
nails brittle, break easily
nausea
need daily coffee, tea, or cola (caffeine)
night sweats
no energy to exercise
often awake between 2-3 a.m. (not because I’m hungry)
oily skin
PMS (cramps, nausea, headaches, irritability, etc.)
rashes, dermatitis, itching skin, or hives often
sleepy, drowsy during the day
slow to get going in a.m. and/or like to sleep late
sodium retention (medically diagnosed)
spider veins
swelling or puffiness under eyes
tender breasts
thin or delicate skin
tire easily, low stamina/endurance
tired/low energy, especially in afternoon
unable to get pregnant
unable to maintain pregnancy
urinate frequently
uterine fibroids
vaginal dryness
wake up feeling tired or unrested
The list continues...
*
absentminded frequently
ADD/ADHD experience
angry often
anxiety, anxiousness (can be for no apparent reason)
apathetic
avoid emotional confrontations or situations
best sleep often between 7 – 9 a.m.
can’t think clearly
concentration difficult
decreased ability to handle stress or pressure
decreased tolerance of others
depression, sadness, melancholy
despair
emotionally stressed
fearful (can be for no apparent reason)
feel best in the evenings
feel overwhelmed often
feel unwell often
foggy thinking
forgetful
get confused often
hard to do tasks quickly
hard to get out of bed or get going in a.m.
hard to think or act quickly
have little control over how I spend my time
hopelessness feelings
inability to calm down
insomnia - hard to fall asleep
insomnia - wake up & can’t go back to sleep
irritability
just don’t feel right, not myself
lack drive, motivation
learning is difficult
less productive than in the past
loud noises bother
memorization difficult
memory poor
mentally stressed
mood swings, emotional ups and downs
must force myself to keep going
nervous breakdowns
nervousness
panic attacks
procrastinate often
shake or feel nervous under pressure
sleeping pills needed for sleep
spacey, hard to focus
startle easily
stress or pressure causes me to lie down and rest
suddenly run out of energy
tearful, could cry easily
thinking gets confused when under pressure
thinking not as clearly as in the past
thoughts too many, too rapid
timid, overly cautious
upset easily
work best late at night
worry
Section three...
*
arthritis, osteo
arthritis, rheumatoid
circulation poor
difficulty building muscle
losing muscle mass
low back pain
muscle weakness
osteopenia
osteoporosis
pain in jaw (TMJ)
pain in joints (not due to injury)
pain in low back area
pain in lower neck
pain in sciatica
pain in shoulders
pain in upper back
sprains or strains occur easily or often
stiffness or achiness, especially in morning
Section four...
*
alcohol intolerance
anger, irritability relieved by eating
craving for sweets
excessive hunger
feel faint often
feel weak
hyperglycemia–high blood sugar
hypoglycemia–low blood sugar
insulin resistance
light-headed often
nausea, eating relieves
often awake between 2-3 a.m. and need to eat something
shakiness, nervousness relieved by eating
Section five...
allergies - food
allergies – other inhalants
allergies – seasonal (hay fever)
allergies are worsening (severity, frequency, or to more things)
bacterial infections
catch colds easily
CFS-chronic fatigue syndrome
chemical sensitivities
coughs or colds usually last for several weeks
environmentally sensitive, reactive
food intolerances, reactivities, or sensitivities
fungal infections
get sick easily or often
gum infections (gingivitis)
headaches
immune deficiency
inflammation (not due to injury)
often get colds or flu
pain (not due to injury)
parasite infections
sensitive to odors, flowers, or chemicals
sick more often, takes longer to get well
sinus problems
tooth infections (pyorrhea)
urinary tract infections
viral infections (cmv)
viral infections (ebv)
viral infections (herpes)
yeast infections (candida)
Second to last section
*
acne
alternating constipation and diarrhea
aversion to certain foods
bloating
burping or belching
constipation (b.m. less than once a day)
dark circles under eyes
diarrhea
exposure to environmental toxins
heavy metal accumulation
intestinal gas
irritable bowel
kidney disorders
leaky gut
liver disorders
loss of appetite
lung disorders
often have nightmares
rashes, hives often
skin problems, bad skin, bad coloring
strong body odor
sweat burns my skin
Last few
*
digestive disorders
slow healing
sweat has an ammonia odor
unable to lose weight
unintentional weight loss
weight 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.
Please Select
Yes
No
Still learning.
If accepted, what day next month would you hope your in-take call would be on?
-
Month
-
Day
Year
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!
Submit
Should be Empty: