Health Quiz

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

GoodFairPoor

YesNo

Please describe Your top three concerns here. Be as detailed as possible*

Are you under the care of a physician or specialist? If yes, for what?*

Are you currently taking any medications or supplements? (list)*

What treatments have you tried?*

What has worked?*

Do you have any pets or farm animals? If yes, where do they live?*

Have you or your family recently experienced any major life changes? If yes, please comment: *

Have you experienced any major losses in life? If so, please comment:*

Did you feel safe growing up?*

Have you ever struggled with an eating disorder. If yes, please describe. Be as detailed as possible. *

Have you been involved in abusive relationships in your life?*

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?*

Do you feel safe, respected and valued in your current relationship?*

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?*

Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues?*

List past Medical and Surgical History:*

How often have you taken antibiotics? (How many times/how long ago?*

How often have you have taken oral steroids?*

What medications are you taking now, and what are they for? *

As a child did you eat a lot of sugar and/or candy? *

What is your typical daily diet:*

How much of the following do you consume each week?Tea:Coffee:Soda:Other Caffeine:Dairy:Cheese:Bread:Sugar:Candy/Chocolate:Dessert:*

Is there anything special about your diet that I should know?*

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)?*

Do you feel much worse when you eat certain foods?*

Do you feel much better when you eat certain foods?*

Have you ever had a food that you craved or really "binged" on over a period of time?*

Do you have an aversion to certain foods? If yes, what foods?*

How many times per week do you drink alcohol?*

Do you have mercury amalgam fillings in your teeth? If so, how many?*

Do you have any artificial joints or implants? If so, which ones.*

Do you feel worse at certain times of the year?*

List your hobbies and leisure activities:*

Do your parents or siblings have (or had) any health issues? If so, please explain:*

Why do you believe you would be a good candidate to work with Mikki?*

Are you triggered by other religions, or spiritual beliefs? if yes, please explain - with as much detail as possible. *

On a scale of 1–10, how is your daily energy?*

How many times per week do you feel stressed, anxious, or overwhelmed?*

Do you experience brain fog, fatigue, or mid-day crashes?*

How do you usually cope with stress?*

Other ________________________________________________________

On a scale of 1-10, how would you rate your Nutrition & Digestion*

Other ________________________________________________________

How many times per day do you have a bowel movement?*

Other ________________________________________________________

Please describe digestion issues, if any *

How many glasses of water do you drink per day?*

Do you drink filtered, tap, bottled, or ionized water?*

How many servings of fruits/vegetables do you eat daily?*

How much caffeine do you consume?*

How many hours of sleep do you get on average?*

Do you have trouble falling asleep or staying asleep?*

Do you wake up feeling rested?*

How often do you exercise or move your body? (type + frequency)*

Do you spend time outdoors or in natural light daily?*

Do you smoke or vape?(how often)*

Have you ever done a detox or cleanse? (describe)*

Are you regularly exposed to chemicals, heavy metals, or mold (at work or home)?*

Do you use conventional personal care/cleaning products or non-toxic/organic?*

Do you notice sensitivities to perfumes, fragrances, or foods?*

Do you journal? (Please describe which/how often)*

Do you Meditate? (Please describe which/how often)*

Do you practice breathwork? (Please describe which/how often)*

How would you describe your mood most days?*

Do you feel connected to a sense of purpose or passion in life?*

Do you have a strong support system (family, friends, community)?*

What is your budget for coaching? *

What is your current Job? *

Are you happy in your Job? *

What are your top 3 goals for working together?*

What would success look like for you in 3 months? PLEASE BE SPECIFIC*

YesNo

Are you ready and willing to make changes in your daily routine? (Yes/No/Maybe)*

Your Location

Area or City

Disclaimer: I am not a licensed medical doctor, psychologist, or healthcare provider. I am a certified Integrative Health Practitioner and coach. The services, coaching, and tools provided through Mentor With Mikki / New Health Rebellion are educational and supportive in nature. The information on this form, in our sessions, and in any related resources is not intended to diagnose, treat, cure, or prevent any disease.Always consult with your qualified healthcare provider before making changes to your diet, lifestyle, medications, or supplements.By submitting this form, you acknowledge that you are taking full responsibility for your own health decisions and outcomes.You release and hold harmless Mentor With Mikki / New Health Rebellion from any liability related to your participation.

By submitting form you agree to this statement

Privacy Notice - Your privacy matters to me. The information you provide in this Health Assessment Questionnaire is strictly confidential. It will only be used by Mentor With Mikki / New Health Rebellion for the purposes of coaching, wellness planning, and communication with you. I will never sell, rent, or share your personal information with third parties. Your data is stored securely through Jotform and associated integrations (e.g., email, scheduling, CRM). You may request to review or delete your information at any time by contacting me directly at yourwaterlady@gmail.com By submitting this form, you consent to the collection and use of your information as described above.

By submitting form you agree to this statement