Welcome

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CLIENT INFORMATION

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Name* This field is required.

First and Last Name

Preferred Name

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Date of birth

Date

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Email* This field is required.

example@example.com

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Phone Number* This field is required.

Please enter a valid phone number.

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State you reside

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Are you currently pregnant or breastfeeding?

YESNO

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If yes please explain

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PRIMARY REASON FOR CONSULTATION

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What is your main reason for scheduling this consultation?* This field is required.

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What symptoms or concerns are you currently experiencing?* This field is required.

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How long have these concerns been present? * This field is required.

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What feels most urgent for you right now?* This field is required.

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What would you like to feel differently after working together?* This field is required.

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MEDICAL AND HEALTH HISTORY

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Have you been diagnosed with any medical conditions? If yes please explain* This field is required.

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Are you currently under the care of a medial provider? If yes for what? * This field is required.

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Are you taking any medications? Please list name, dosage and reason* This field is required.

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Have you had any surgeries or hospitalizations? If yes please explain* This field is required.

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Have you had any major illnesses, injuries, or infections in the past? If yes please explain* This field is required.

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HORMONES AND REPRODUCTIVE HEALTH

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Age at first menstrual cycle* This field is required.

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Are your cycles regular? * This field is required.

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Average length of cycle* This field is required.

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Have you used hormonal birth control in the past? If yes for how long and what type? * This field is required.

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Pregnancy history* This field is required.Please list your pregnancies, love births, abortions, and miscarriages

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DIGESTION AND GUT HEALTH

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How would you describe your digestion?* This field is required.Please include any bloating, gas, reflux, constipation, or diarrhea

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How often do you have bowel movements?* This field is required.

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Do you notice reactions to certain foods?* This field is required.

YESNO

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Have you ever been diagnosed with food allergies or sensitivities? * This field is required.

YESNO

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If yes please explain* This field is required.

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ENERGY,MOOD, AND STRESS

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How would you rate your daily energy levels?* This field is required.

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Do you experience any of the following?* This field is required.

Fatigue

Burn out

Anxiety

Low mood

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How is your sleep quality. * This field is required.Include how many hours you get every night

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Do you have difficulty falling asleep?* This field is required.

YESNO

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How would you describe your stress levels?* This field is required.

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What are your biggest sources of stress?* This field is required.

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NUTRITION AND LIFESTYLE

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Describe a typical day of eating* This field is required.

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How often do you eat protein? * This field is required.

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Do you follow any specific diet or food philosophy?* This field is required.

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Do you consume any of the following?* This field is required.

Caffeine

Tobacco

Nicotine

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How often do you move your body? Speaking about working out

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What does movement look like for you?* This field is required.

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SUPPLEMENTS AND REMEDIES

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List all supplements, herbs, or remedies you are currently using* This field is required.

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How long have you been using them?* This field is required.

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Have you noticed any benefits or reactions? If yes please explain* This field is required.

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ENVIRONMENTAL AND LIFESTYLE FACTORS

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Do you work with chemicals, fragrances, or toxins regularly ?* This field is required.

YESNO

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Do you use any scented personal care or cleaning products?* This field is required.

YESNO

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Do you filter your water?* This field is required.

YESNO

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Any known mold exposure?* This field is required.

YESNO

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TESTING AND LABS

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If you had any recent lab work or testing please list in below and attach the file in the next question if it’s available. * This field is required.

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File Upload

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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GOALS AND EXPECTATIONS

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What does success look like for you?* This field is required.

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What are you hoping to understand more clearly about your body?* This field is required.

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Are you open to lifestyle, nutrition and habit changes?* This field is required.

YESNO

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CONSENT AND UNDERSTANDING

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I consent and understand that this holistic consultation is educational and holistic in nature and does not replace medical care. * This field is required.

YESNO

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I understand that recommendations are supportive and not medical diagnoses or treatment. * This field is required.

YESNO

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Signature* This field is required.

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Date* This field is required.

Date

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Schedule your consultation