Health Questionnaire
Please fill out the questions to understand your state of health.
Name
First Name
Last Name
Email
example@example.com
Age
Height
Weight
Have you ever been medically diagnosed by a doctor with anything? Please name any and all diagnoses, as well as any medications you have or are taking for this condition. Please include past conditions that are not affecting you today.
What do you feel are your most pressing health concerns? What would you like to address in our sessions?
When did these concerns begin to appear? Can you trace them back to a certain event or period in life?
Can you describe how these problems have changed over time?
Did you experience any illnesses that occured frequently when you were a child? If so, what were they?
What kinds of foods did you prefer to eat as a child or teenager?
What kind of hobbies did you have when you were a child? Do you still do them now? Why or why not?
What kind of activities do you do to relieve stress?
How would you describe your sleep?
Is there anything you would like to fix about your sleep?
What is your sleep routine?
How consistent is your sleep? What time do you go to sleep, and wake up?
Do you have any other sleep issues?
How do you feel when you wake up?
What is your morning routine, if you have one?
How would you describe your energy levels throughout the day?
How much caffeine, and what kind of beverages, do you consume? When is the first time you consume it, and the last?
How much water do you drink throughout the day? When do you start and end drinking water?
Do you or have you followed a restrictive diet? (Keto, vegan, vegetarian, raw, etc)
How long were you, or have you been on this restrictive diet?
What improvements occurred on this restrictive diet? What issues were you trying to address with this diet?
Describe your diet in the most comprehensive way possible, including why you chose these food habits.
How many meals a week do you eat of home cooked food?
How many meals do you eat out at restaurants?
What kind of fats do you cook with? (Olive oil, butter, margarine, etc)
What foods do you like to eat often? Foods that are in your grocery cart almost every week.
What would you consider to be the 3 healthiest foods you regularly consume in a week? Why are they healthy?
What would you consider to be the 3 UNHEALTHIEST foods you regularly consume in a week? Why are they UNHEALTHY?
Describe to me, in your own words, your experience of eating and digesting food. What are some experiences that the questionnaire did not capture?
Have you been medically diagnosed with any gastrointenstinal issues in the past? If yes, please describe them.
Do your currently use any pharmeuticals or supplements to aid you in any part of your digestion? What problem are you intending to fix with them?
Are your bowel movements regular?
How often do you have a bowel movement?
Describe the shape, color, texture, and size of your bowel movements. If they vary from day to day, describe all the variations.
Has your digestion or bowel movements changed in recent memory? If it has, can you trace it back to a certain event or period in life?
Do you experience any frequent or chronic infections? Please list them.
Please list any supplements that you have taken that had a completely unexpected effect. (For instance, did you try some valerian tea, known to be a sedative, and end up feeling energized and staying up all night?)
What is your blood pressure?
Women only: check all the boxes that apply. If you are in perimenopause or menopause, please still answer check the boxes that would have best described your menstrual cycle.
Heavy menstrual flow
Scant flow or mainly spotting only
Flow lasts 6 or more days
Periods are shorter, less than 27 days
Periods are sporadic
Diagnosed with PCOS
Suspect PCOS
Severe cramping
Have you taken birth control in the past
Experienced one or more miscarriages
Undergoing fertility treatments
In perimenopause
First period before the age of 10
Light menstrual flow
Flow last 1 to 3 days
Periods are regularly between 28 to 31 days
Periods are longer, more than 32 days
PMS symptoms
Currently on birth control
Difficulty conceiving
Have done fertility treatments in the past
In menopause
Men only: check all the boxes that apply.
Underactive libido
Wake up at night to urinate
Lost interest in activities you used to enjoy
Have done fertility treatments in the pas
Overactive libido
Pain with urination
Feeling more agitated than you used to
In perimenopause
Is there anything else you would like me to know about your experience in your body? I would like know anything, and everything you would like to share. This gives me a clearer and more comprehensive view of what systems are possibly involved in creating your health experience.
Submit
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