This questionnaire is designed to provide your health professional with the information necessary to build an individualised program based on your unique health history. Please answer the questions as accurately as you can.
Your Health Profile
Major complaints (please list in order of priority). Please indicate for how long you have had these problems e.g: crash dieting 10 years, eczema 3 years.
THE ROOT - Identity, family, nutrition, and systems of survival
Immediate Family Members
Birth family members
NUTRITION
Specific Root Foods & Ways of Eating
Please mark if you regularly follow this way of eating, or consume these foods and/or supplements. Make any comments you feel will be beneficial for your healthcare professional to know.
Body Weight Details
Systems of Survival
Choose all of the conditions you currently have in the first dropdown list and the conditions you have had in the past from the second dropdown list.
Elimination Patterns
THE FLOW – Relationships, emotions, fluidity, and systems of creativity
Specific Flow Foods & Ways of Eating
Systems of Creativity
Menstrual and Pregnancy History (For Women)
THE FIRE – Life balance, energy level, thoughts, and systems of transformation
Describe briefly what gives you energy and what takes it away.
Specific Fire Foods & Ways of Eating
Systems of Transformation
THE LOVE – Fulfilment, movement, oxygenation, and systems of circulation
Specific Love Foods & Ways of Eating
Systems of Circulation
THE TRUTH – Expression, eating, truth, and systems of integration
Specific Truth Foods & Ways of Eating
Systems of Integration
THE INSIGHT – Sleep, dreams, moods, and systems of intuition
Specific Insight Foods & Ways of Eating
Systems of Intuition
THE SPIRIT – Spirituality, beliefs, purpose, and systems of connection
Specific Spirit Foods & Ways of Eating
Systems of Spirit