Vanessa Raphael Intake Questions 2024

Please fill out completely and send in the completed form at the latest 48h before our appointment or the appointment will be cancelled and you will need to reschedule.

My forms are very detailed so we can get as accurate a picture of you as possible.

If something doesn't apply to you then write n/a for not available.

This form is about to following up on your symptoms, protocols and I will need to know your current contact details.

Thank you in advance and we'll talk soon,
— Vanessa Raphael

(This form is protected and for my eyes only).

PS: If you want to take a break from filling out this form, you can scroll down and press "SAVE" to continue later.

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth

Date

Gender

Email

example@example.com

Can I reach you on Skype / WhatsApp / Messenger? If yes please specify which platform you prefer and your username / number

e.g. WhatsApp same as phone number

Phone

Include your country code e.g. 001 (USA) or 0047 (Norway)

Country

Relationship status

Occupation

Work hours per week

Referred by

Paternal Family Illnesses (Father and his parents if applicable)

Maternal Family Illnesses (Mother and her parents if applicable)

History of illnesses (Diagnosis, Date of Onset)

Bones

Boobs

Cravings

Eyes

Fatigue

Gut

Hair

Brain

Heart

Nervous system regulation

Incontinence

Joints

Menstrual

Mental

Mouth

Muscles

Nails

Odor

Periods

Respiratory

Sex

Skin

Sleep

Tingling extremities

Vagina

Voice

Weight

Other symptoms or need to write more details?

History of hospitializations / surgeries (Diagnosis, Years / dates)

Have you ever taken antibiotics?

If you have taken antibiotics, when?

Have you ever taken birth control?

If you have taken birth control, what type?

If you have taken birth control, what age did you start and stop?

Have you ever been on hormone replacement therapy?

If you have been on hormone replacement therapy, what type?

If you have been on hormone replacement therapy, what age did you start and stop?

Age started having periods?

Are you taking progesterone? If yes: How much per day, what brand and how many days of your cycle?

Are you taking estradiol? If yes: How much per day, what brand, oral / patch / cream / gel / spray and how many days of your cycle?

Are you taking estriol? If yes: How much per day, what brand, cream or (?) and how many days of your cycle?

Are you taking testosterone? If yes: How much per day, what brand, oral / cream / gel and how many days of your cycle?

Regular or Irregular periods when NOT on birth control and CYCLING NORMALLY?

How many days would you bleed?

Have you ever been pregnant?

If you have given birth, how did you give birth: Vaginal birth and / or C section?

Did you breastfeed? How log with each pregnancy?

How old were you with each pregnancy?

Last pap and mammogram?

What age were you when cycles stopped? Naturally or with hysterectomy?

List all supplements you're currently taking including vitamins, herbs, minerals.

Supplement name, Dose, Frequency, Start Date

List all medications you're currently taking.

Medication name, Dose, Frequency, Start Date

Do you use or have you used recreational drugs?

Drugs name, Dose, Frequency, Start Date

Do you take annual flu vaccines?

Which brand and how many shots

Did you take Covid19 vaccines?

Which brand and how many shots

List any other vaccines that you remember taking (bird flu, swine flu, cholera, etc)

Which brand and how many shots

List any food- or environmental allergies that you experience?

Do you consume coffee? If yes how often?

Do you consume alcohol? If yes how often?

How many cigarettes do you smoke per day?

Please specify if cigarettes, shisha, weed, etc

For how many years have you smoked?

If you have quit smoking, how long ago?

Do you get at least 5 hours of un-interrupted sleep per night? If not, please indicate why not.

How much do you weigh?

What is your ideal weight?

How tall are you?

Age

Occupation

How did you find me?

Check off what is true for you

Please describe your digestion

How are your bowel movements

How is your urination?

Describe your libido or sexual energy, i.e. low libido, normal, painful

Women: Please describe in detail your cycles or your menopause experience

Do you exercise regularly and if so in what form? (e.g "I cycle for 30min 5 times per week" or "I attend movement therapy classes at the swimming hall once a week")

List you main stressors:

Check off all that apply (both drinking and eating)

Please describe your average breakfast

Please describe your average lunch

Please describe your average dinner

Please describe your snacking habits, include your cravings

Are you handy in the kitchen? Do you like to cook?

How much vitamin D3 are you currently taking? (if you take any)

How much iodine are you currently taking? (if you take any)

Are you using toothpaste that contains fluoride?

Please describe your dental health. (e.g. "I have one or more cavities, crowns, root canals.")

Do you have amalgams or other inventions in your mouth lie a gold tooth, plastic etc?

How much pure water do you drink daily & what type?

The sun quality of where I live is

Exposure to sun and daylight

Mindset is very important for healing. Do you have any underlying beliefs that you are deserving to be sick? Your own fault? Religoius beliefs? Please explain

What emotions do you feel the most often?

If I feel down, sad or depressed, I tend to:

What makes you come alive? (e.g.: a hobby, helping people, making music, the outdoors, a good book, etc)

Is there anything else you'd like to share with me that is not covered in this questionnaire?

What are your major health complaints?

How often does it / do they bother you?

How long has it been going on for?

What have you tried so far that has not worked?

How does this affect your life or what does it prevent you from doing?

Who or what (fear, money, time) may stop you from completing a health rebuilding program?

Do you have people around you to support your health journey?

What would you (reasonably) expect to achieve while working with me?

What do you (reasonably) hope to achieve from working with me? I.e "I want to get BHRT coaching" or "I want to learn how to address my Endometriosis" or "I want to loose 14 pounds with diet, supplements and lifestyle."

On a scale of 1 – 10 what is your level of commitment to improving your health? (1 = lowest, 10 = highest)

On a scale of 1 – 10 what is your level of financial commitment to improving your health? (1 = lowest, 10 = highest)

My fees are ranging from $300 per consultation unless other prices are given as part of a special deal. Do you have the funds to work with me? (see my website for affordable D.I.Y. programs if not)

Disclaimer: "I am aware that Vanessa Raphael is NOT a medical doctor. She is a functional health practitioner and brain & hormone coach and does not intend to diagnose, treat or cure any illness or disease that I may be suffering from"

Initial Intake Questions

Family Health History

Personal Health History

Symptoms

Let's sum it up