Outlier Health: Comprehensive Intake Assessment
Personal Details, Health History and Subjective Experience
Personal Contact Details
Please provide your current contact details for all follow up and support
Name
*
First Name
Last Name
Date of Birth
*
(DD/MM/YYYY)
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State & Postcode
Country
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram Handle
@example
Preferred Primary Method of Contact
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Objective Measures: Metabolic and Energy Balance
Please provide your basic composition details below
Current Age
Height
(cm)
Current Weight
(kg)
Ideal Weight
(kg)
Body Fat Percentage (if known)
Provide body fat % if known
Historic / Current Issues with Fat-loss
Please Select
Yes
No
Unsure
Historic / Current Issues with Muscle Gain
Please Select
Yes
No
Unsure
Current Activity Levels (not including exercise)
Highly Active / Physical Job (labourer / farmer and physical hobbies etc)
Moderately Active (partially physical job and numerous physical hobbies)
Somewhat Active (office job / a physical hobby)
Sedentary (office job / no physical hobbies etc)
Current Exercise Frequency and Intensity
High - 7 days a week / multiple hard training sessions
Moderate - 3-4 days a week / mostly hard training sessions
Somewhat - 1-3 days per week / occasionally hard training sessions
Easy - 1 - 3 days per week / gentle training / walking
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Health Info
Please provide any current and historic health information below
Current Known Prevailing Health Issues
Professionally or self-diagnosed
Any Current Medical Diagnosis
Provide any current, professional diagnosis being treated for
Current Medications
Provide any current medications being taken or prescribed
Current Supplements
Provide any current supplements being taken regularly
Current Doctor / Health Practicioner
Provide details of current health care professional
Recent / Resolved Diagnosis's
Provide any previous diagnosis / remissive diseases
Recent Surgeries
Provide any previous surgeries, i.e; gallbladder removed, appendix, tonsils removed etc
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Health History
Comprehensive Lifetime Health Overview
Provide Any Known Familial, Hereditary or Genetic Health Issues
Provide any health issues running through at least the previous two generations
Provide Any Known Ancestral / Intragenerational Trauma / Health Issues
Provide Any Known Intrauterine Trauma / Health Issues
Provide any details of known experiences whilst in utero
Provide Any Trauma / Interventions / Health Issues (Birth to 7 years old)
Provide any known health issues from birth until the age of 7. Including any serious illnesses, surgeries, traumatic experiences, vaccinations or health complications
Provide Any Trauma / Interventions / Health Issues (7 to 12 years old)
Include any serious illnesses, surgeries, traumatic experiences, vaccinations or health complications
Provide Any Trauma / Interventions / Health Issues (12 to 17 years old)
Include any serious illnesses, surgeries, traumatic experiences, vaccinations or health complications
Provide Any Trauma / Interventions / Health Issues (17 to 27 years old)
Include any serious illnesses, surgeries, traumatic experiences, vaccinations or health complications
Provide Any Trauma / Interventions / Health Issues (27 - 37 years old)
Include any serious illnesses, surgeries, traumatic experiences, vaccinations or health complications
Provide Any Trauma / Interventions / Health Issues (37 + years)
Include any serious illnesses, surgeries, traumatic experiences, vaccinations or health complications
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Work History
Please provide an overview of work and working history below
Current Occupation
Provide your current occupation
Hours Generally Worked Per Week
Provide an average amount of hours generally worked per week at the above occupation
Current Occupational Fulfillment
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Occupational Stress
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Injuries / Niggles / Soreness / Movement Limitations
Provide any current injuries or physical issues
Previous Occupations
Provide a list or overview of previous occupations, especially any with environmental concerns or impacts, i.e; painter, asbestos removalist etc
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Stress, Relationships and Mood
Please provide details of your current state of stress and mood below
Current Stress Levels
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Known Triggers / Causes
Provide any known exaccabators of stress levels
General Mood
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Known Impactors on Mood
Provide any known reasons for mood issues
General Outlook on Life
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Known Impacts on General Outlook
Provide any known experiences which impact general outlook and attitude towards life
Current Energy Levels
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Known Impacts on Energy Levels
Provide any known experiences which negatively or positively impact energy levels
Current Libido
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Relationship Experience with Parter
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Relationship Experience with Family
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Relationship Experience with Friends
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Relationship Experience with Children
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Current Social Life / Experiences
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
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Sleep Overview
Please provide insight into current sleep details below
How Well Do You Generally Sleep
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Average Hours of Sleep Per Night
Provide an estimate of hours slept per night
Known Sleep Issues / Diagnosis
Provide any known sleep issues, i.e: frequent waking during the night; nightmares; insomnia; sleep apnea etc
How Regular is You Sleep Timings
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Usual Bed Time
Hour Minutes
AM
PM
AM/PM Option
Usual Waking Time
Hour Minutes
AM
PM
AM/PM Option
Weekend Bed Time
Hour Minutes
AM
PM
AM/PM Option
Weekend Waking Time
Hour Minutes
AM
PM
AM/PM Option
Once in bed, how long does it normally take to fall asleep?
10 - 15 minutes
15 - 30 minutes
30 - 60 minutes
60 + minutes
Do you snore loudly?
Yes
No
Unsure
Do you often feel tired, fatigued or sleepy during the daytime?
Yes
No
Unsure
Has anyone observed you stop breathing during sleep?
Yes
No
Unsure
Do you have or are you currently being treated for high blood pressure?
Yes
No
Unsure
Do you often wake up before the alarm?
Yes
No
Sometimes
Unsure
Do you often need to snooze the alarm?
Yes
No
Sometimes
Unsure
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Lifestyle Overview
Please provide details of your current lifestyle below
Time Spent in Nature Per Week
7 - 10 + hours
5 - 7 hours
2 - 5 hours
Less than 2 hours
Sun Exposure Frequency
High - 30 mins + / 7 days a week
Moderate - 30 mins + / 3-5 days a week
Intermittent - Less than 30 minutes / 1-2 days a week
None - No sun exposure through the week
Most Common Time of Sun Exposure
Hour Minutes
AM
PM
AM/PM Option
Regular Daily Step Count
Provide a general overview of regular daily step count
Most Common Forms of Exercise Undertaken
Weightlifting / Circuit Training / Gymnastics
Running / Cycling / Swimming
Walking / Yoga / Dance
Hiking / Rock Climbing / Outdoor Activities
Time Dedicated to Exercise Per Week
7 - 10 + hours
5 - 7 hours
2 - 5 hours
Less than 2 hours
Time Dedicated to Exercise Recovery Per Week
7 - 10 + hours
5 - 7 hours
2 - 5 hours
Less than 2 hours
Provide Any Methods Currently Being Used to Manage Stress
Meditation / Mindfulness / Metacognition
Tai Chi / Movement / Active Meditation / Somatic Practices
Breathwork / Mantra's / Chanting
Positive Psychology / Mindset / CBT / EMDR
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Looking Forward
Please provide details in working together
Biggest Current Health Concerns
Previous Interventions Undertaken
Provide any previous interventions sought for current health issues, i.e; allopathy, naturopathy, TCM, Ayu Vedic etc. Also provide the year, duration and all known positive or negative experiences and outcomes.
Expectations of Outcome in Working Together
Provide any expectations of working with me
Biggest Limitations to Health
Provide an outline of what you believe to be the biggest limitation to being healthy.
What does being healthy mean to you...
Provide an overview of what being healthy looks like to you
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