Wellness Survey

Hi! I'm Elizabeth, a Functional Nutrition & Medicine Practitioner!

I love helping everyone find healing (yes, you deserve it!).

If you're tired of hearing that your labs are normal, being presented with bandaid solutions, or being prescribed medication by a Doctor, you've come to the right place!

I can't wait to learn more about you!
Health Survey

Please fill out this health survey
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Where do you live?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contacts

Phone CallEmailText MessageOther
Birth Date

MonthDayYear
Age
Ex:23
Gender
What do you do for work?
Medical
Are you currently taking any medication? If so, please list them here.
List any supplements your taking:
Do you have any food allergies? If so, please list.
Do you have any food allergies?

YesNo
Are you pregnant or nursing?
Have you taken antibiotics in the past?

Yes, within the past 5 yearsYes, but over 5 years agoNo
Have you ever been on or currently taking birth control? If so, when and for how long?
Body Info
Height
Height in inches
Weight
Weight in lbs
Are you happy with your current body weight?
Describe what your cycle is like:
Sleep
In general, at what time do you go to bed and wake up?
In general, when do you wake up?
On average, how many hours of sleep do you get?
Do you wake up feeling rested?

YesNoOther
How is the quality of your sleep?
Hydration
In a day, how much water do you drink usually?
In a day, how much coffee do you drink usually?
In a week, how much alcohol do you consume usually?
Do you take electrolytes? Or drink coconut water?
Movement
Do you do any exercise?

1 - 3 a week3 - 5 a weekEverydayNever
What kind of exercise do you participate in?
Are there things you would like to do that you are currently unable to?
How would you rate your daily energy level?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Stress
What do you do for work?
Do you enjoy what you do?
Are there any other stress in your life?
Eating Habits
When do you eat your first meal?
How many calories do you normally eat a day? (if you don’t know, guess or leave blank)
How many meals per day do you eat?
Do you snack? If yes, what do you snack on?
How often do you eat out in a week?

AlwaysUsuallySometimesRarelyNeverOther
What does a typical day of eating look like? What foods do you eat?
How much protein do you eat? Where source do you get your protein from?
Do you have food cravings (salty, sweet or both)? Do you eat gluten? Dairy? Eggs?
What about fat intake? What are your main sources of fat?
Digestion
What are the consistency of your BMs like? How often?
Do you have any of the following?

Belching/burpingAcid refluxNausea
Any gut discomfort or pain?
Do you have any of the following: floating stool or undigested food in your stool?
Please list anything else you want to add to digestive issues.
Health History
Do you smoke? If so, how much?
Any recent travel in the last 1-2 years?
Do you eat sushi, if yes, how often?
Have you had any sort of trauma happen that you feel comfortable sharing? You can just write yes or no too if that’s easier.
Do you struggle with anything mentally? Anxiety, depression, insomnia, OCD?
Do you get headaches?
Do you have any medical conditions such as autoimmune, allergies, etc?
Does anyone in your family have autoimmune?
How committed are you to lifestyle changes?
Working with a coach takes commitment financially and with lifestyle change, how prepared and ready are you to commit to both of those?
What are your goals in 90 days? What does that look like to you? What would it feel to reach them?
Any known MOLD exposure?
What are your main symptoms or concerns you want to address or discuss?
If you could waive a magic wand when it comes to your hair, skin, health, mood, and energy, what would you want? Be specific.
Do you believe in yourself?
Are you currently working with a doctor? What kind?
Have you ever worked with a naturopath or someone in functional medicine?
Do you have any labs or additional documents you’d like to share?

Cancelof
Is there anything else you’d like to share?
By checking “I agree”, you acknowledge that Elizabeth McMillin is not a Medical Doctor. Elizabeth is a functional medicine practitioner and coach, and the information provided is intended to support and guide you in achieving your wellness goals. Her advice is based on general knowledge and experience in functional health and is offered as suggestions only.*

I agree
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Type a question
Should be Empty:

Health Survey

Medical

Body Info

Sleep

Hydration

Movement

Stress

Eating Habits

Digestion

Health History