Inher Health Clinic
This form must be filled out before your health analysis
Full Name
*
First Name
Last Name
Birth date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about Inher Health Clinic?
*
Please Select
Radio
Instagram
Facebook
Referral
What service have you booked in for?
Please Select
Health Analysis
Mini Script Consult
If you were a prior client of PBPN/ Inher Health Clinic please state what service you were apart of
Please give a detailed explanation of your health concerns
Whats your primary goal from working with IHC?
Please state what current supplements you are taking (including doses and brands)and also including western medication + hormonal birth control
Give me what an ideal dietary day looks like for you with foods you enjoy
Now please give me an actual 3 day diary of what you have eaten in the last 3 days (if you count calories , macros or have an understanding of nutrition - please include this)
Please list any food dislikes, intolerances and allergies
What behaviours/factors do you have that are holding you back from meeting your dietary expectations/goals
Please describe to me your menstrual cycle (regular/ irregular, how many days, long/short/heavy/light bleeds)
Please describe to me your bowel movements and gut health
Please give me a detailed family history (auties, uncles, grandparents, siblings and parents) - depression, anxiety, autoimmune diseases, heavy bleeds, endo/PCOS, thyroid, cancer, heart disease, stroke, cancer etc
What injuries do you have currently and have had previously - please include your surgeries you have had as well (including cosmetic)
If you have been pregnant before, please give me a detailed run through of how your pregnancy(s) went and how your birth experience went
Please explain your childhood , including trauma and illnesses
Please explain your timeline history of place of residance (where you have lived) - including the quality of the houses and type of environment
Please explain your employment history and how this affected sleep, nutrition and wellbeing
Please explain your relationship history and how this affected sleep, nutrition and wellbeing
Please explain your current mental health status and history
Please explain your energy levels
Provide me with any further information you can think of that could be relevant to your health analysis
Have you provided pathology ? (Blood results)
Yes
No
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