Health & Inner Experience Assessment 🌿✨

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Intro
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Full Name* This field is required.
First Name
Middle Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Email* This field is required.
example@example.com
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Phone Number
Please enter a valid phone number.
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Concern 1 Name* This field is required.
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Concern 1 Description* This field is required.Please describe this concern in as much detail as possible. You may reflect on: What exactly happens The sensation or type of discomfort What makes it worse What brings relief Triggers Timing (when it occurs) When it began and what was happening in your life at that time Any associated symptoms
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Concern 2 Name (Optional)
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Concern 2 Description (Optional)Please describe this concern in as much detail as possible. You may reflect on: What exactly happens The sensation or type of discomfort What makes it worse What brings relief Triggers Timing (when it occurs) When it began and what was happening in your life at that time Any associated symptoms
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Concern 3 Name (Optional)
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Concern 3 DescriptionPlease describe this concern in as much detail as possible. You may reflect on: What exactly happens The sensation or type of discomfort What makes it worse What brings relief Triggers Timing (when it occurs) When it began and what was happening in your life at that time Any associated symptoms
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Food cravingsFood items you really crave strongly
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Foods you strongly dislikeFood items you dislike really strongly
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Foods that consistently make your symptoms worseFood items that cause you problems and describe what happens from that item
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Foods or drinks that tend to make you feel betterFood items that help you problems and describe what happens from that item
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How is your sleep?Quality of sleep, when do you go to bed ? what time do you wake up? Any issues there?
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Temperature preference
Warm
Cold
No preference
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How does weather affect you?Do you feel better or worse in certain kinds of weather. Impact of dry/wet/foggy/hot/cold/sunny/cloudy weather ?
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Sensitivity to noise, light, smells, crowds, etc.Please mention if any such sensitivities
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General energy level
Please Select
Please Select
Very low
Low
Moderate
High
Variable
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Additional details about energy level
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Sexual energy level
Please Select
Please Select
Low
Moderate
High
Variable
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Notes on sexual energy
Should be Empty: