Health Assessment Form
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Back
Next
Are you taking any medications? If yes, please share.
Do you have any allergies? If yes, please share.
Do you have any chronic medical conditions?
Do you have a menstrual cycle? If yes, do you know which phase you are in?
Do you have painful period? Are they regular?
Rate your sleep? 1-10.
How often do you have a bowel movement in a day?
Are you vegan/vegeterian/meat lover?
Do you exercices? If yes, how often?
Rate your stress levels? 1-10.
How do you usually manage stress or difficult emotions?
Do you have any skin conditions?
Are you experiencing hair loss? Weak nails?
Do you have cravings? If yes, how often? How strong?
Roughly estimate how many grams of sugar you have daily? (1 teaspoon= 4g)
Are you currently taking supplements? If yes, which one?
When was your last blood test? Any deficiency you were made aware of?
Is weight loss a goal for you?
Have you ever been diagnosed with any hormonal imbalance?
What health challenge are you experiencing?
Tell me about yourself/lifestyle/hobbies/work.
What is your health goal?
Submit
Should be Empty: