Personal Health Assessment [PHA]

Personal Health Assessment [PHA]
Welcome to your Personal Health Assessment (PHA). This is your chance to pause, reflect, and really tune into where your health is at right now. By shining a light on the details, you’ll bring your wellbeing to the forefront and give yourself the gift of awareness—the very first step in creating lasting change.

It’s completely normal for this process to stir up different emotions—sometimes it feels exciting, sometimes confronting, and sometimes a little deflating. Remember, this is not about judgment. It’s about giving yourself the opportunity to see the bigger picture and step into a new level of self-care that you may never have experienced before.

Once completed, a copy will be securely emailed to you and Natalie Woodman Clinic. We keep your information on file in accordance with our Terms & Conditions, Privacy Policy, and Personal Information Collection Statement. Your information is treated confidentially and used when you book a consult with us.

We HIGHLY recommend you take photos (front, side and back profile) PLUS any visual health issues (e.g. eczema, psoriasis etc) to track the visual changes as you take charge of your own health.

Instructions...
1. At the end of the first page (section) you MUST click the SAVE button. This will prompt you to create an account (with JotForm) which then emails you a link email link to your saved form. Check junk/spam folder if the link is not in your inbox. Email comes from noreply@jotform.com
2. At the end of every page (section) ENSURE you click the SAVE button, then click NEXT if you are still continuing. This way you will never lose any inputted information. Your JotForm email link will take you to the place on the form where you left off. This way you can NEVER lose any of your information.
3. Your PHA may take up to 60-mins to fill in.We HIGHLY recommend that you give yourself the time YOU deserve and do NOT rush.
4. If you need ANY assistance, please email our client support team, Mon-Fri, 9am-4pm (AWST) at hello@nataliewoodman.com
Full Name

First NameLast Name
Date of Birth*

DayMonthYear
Date
Email Address
example@example.com
Occupation

HEALTH, MEDICATIONS AND SUPPLEMENTS
List ALL the health issues (even little niggles) you are CURRENTLY experiencing (in point form) AND since "when" you've had them e.g. Bloating for 1-year, Rosacea since 2025, Constipation for 30-years, Carrying 20kg+ for 5-years etc...
Using ONE line per each medication... List all prescribed medications (including contraceptives) AND any over-the-counter drugs (e.g. Nurofen, Panadol etc.) you are currently taking (not supplements) If NONE, please type in NONE*
Using ONE line per each Supplement i.e. pills, powders, tonics etc. List all supplements that you take (even if sporadic) and how often. If NONE, please type in NONE*
Using ONE line per each prescribed (e.g. medicinal cannabis) drugs or recreational drugs (incl. cigarettes/vaping) you use (even if sporadic) and how often. If NONE, please type in NONE*

SLEEP
How many hours of sleep do you get (on average)*
Your average 'hours' of sleep
Ease of Falling Asleep... rating*
Refers to the time it takes to fall asleep once you put your head on the pillow
Awakenings... *
Refers to the number of times you WAKE UP during 'sleep hours'
Ease of Falling back to sleep after waking... rating.*
Refers to how easily you fall back to sleep after waking
Please write a brief 'appraisal' of how you feel about your sleep

ENERGY…
Energy on waking... rating*
Energy - throughout the day... rating*
Energy - from evening to bedtime... rating*
Please write a brief 'appraisal' of how you feel about your energy

RESPIRATORY AND CIRCULATION...
Asthma and/or Wheezing.. rating*
Hay fever .. rating*
Dark circles under eyes .. rating*
Bags or puffiness under eyes .. rating*
Phlegm in throat and/or postnasal drip .. rating*
Refers to sensation of mucus dripping down the back of the throat from the nasal passages. Constant throat clearing, coughing (esp. at night), sore or scratchy throat, discomfort when swallowing, excessive swallowing to clear your throat. If NEVER, please write "never
Swollen legs, ankles and/or feet .. rating*
Swollen arms, wrists and/or hands... rating*
Please write a brief 'appraisal' of how you feel about your respiratory and circulation health

ACHES AND PAINS...
Headaches and/or Migraines.. rating*
A headache is a pain or discomfort in the head, scalp, or neck. Where as a migraine typically cause moderate to severe throbbing pain, often on one side of the head. Can last from hours to days. May be accompanied by nausea, vomiting, and sensitivity to light or sound.
Headaches and/or Migraines... Describe in detail, location, duration etc.*
What signs and symptoms do you experience? If NEVER, please write "never"
Body aches, pains or spasms... rating*
Refers to any type of ache, pain or spasm anywhere in the body
Body aches, pains or spasms... Describe where and what it's like*
What signs and symptoms do you experience? If NEVER, please write "never"
Restless leg syndrome [RLS]... rating*
Refers to an irresistible urge to move the legs, often accompanied by uncomfortable sensations, particularly in the evening or at night, making it difficult to fall or stay asleep. The condition can be mild or severe and sensations experienced can be a feeling of crawling, tingling, throbbing, pulling sensation, pins or needles or itching feeling in the legs. The urge to move the legs usually occurs during periods of rest or inactivity, particularly when sitting or lying down.
Restless leg syndrome [RLS]... Describe what it's like*
What signs and symptoms do you experience? If NEVER, please write "never"
Please write a brief 'appraisal' of how you feel about your aches and pains

Measurements

IMPORTANT: Once you complete this section at the START of the program... Do NOT weigh or measure yourself again until you are instructed to do at the END of your program!! We are serious!! (More about this in your Coaching videos)
Height (in centimetres)… Please have someone measure for you, do NOT estimate*
Just enter the number NOT the word "cm"
Weight (in kilograms)… Take a note at what time of day, with or without clothes, that you weighed yourself. Do NOT weigh yourself during the program!!*
Just enter the number NOT the word "kg"
Chest (in centimetres)… Measure around the largest part of your chest (breasts) with the tape across nipples. *
Just enter the number NOT the word "cm"
Waist (in centimetres)… Measure at the narrowest part of your waist. *
Just enter the number NOT the word "cm"
Waist-to-height ratio [WHtR]… To calculate, divide your waist circumference by your height e.g. 80(cm) ➗161(cm) = 0.49*
From the WHtR above, select category*
Waist to Height Ratio [WHtR] is a tool for predicting cardiovascular, diabetes and stroke risk, hypertension, and dyslipidemia because it accounts for the distribution of abdominal fat, which is known to increase the aforementioned risks. The WHtR is a measure of fat distribution. A superior tool to detect cardiometabolic risk factors.
Hips (in centimetres)… Measure around the largest part of your buttocks with your heels together.*
Just enter the number NOT the word "cm"
Right thigh (in centimetres) … Stand with your legs slightly apart, measure where the circumference is largest*
Just enter the number NOT the word "cm"
Left thigh (in centimetres) … Stand with your legs slightly apart, measure where the circumference is largest*
Just enter the number NOT the word "cm"
Right bicep (in centimetres) … Measure midway between the top of your shoulder and elbow *
Just enter the number NOT the word "cm". Note: you're not measuring your left bicep.
Body mass index [BMI]…To calculate enter your weight in kilograms and height in centimetres.
From the BMI rating above select category*
Body Mass Index [BMI] is just one of the many tools used to measure ‘size’, relating to body fat, not dependent on your frame. Correlated with total body fat, it does not distinguish fat from muscle or different body fat distributions.
Please write a brief 'appraisal' of how you feel about your measurements and weight

Start of the Program
Instructions...

1. ONLY fill this section in at the START of your program.

2. IF you are at the END of your program do NOT fill this in again, scroll down and complete the End of program section.
Relationships: How do your health issues impact your relationship/activities with partner, children, grandchildren, relatives and friends? (If it has NO impact at all, then write a little about that)
Intimacy: How do your health issues affect intimacy? (If it does NOT affect at all, then write a little about that)
Work: How do your health issues affect your ability to work? Not being able to concentrate? Feeling overwhelmed? Having to take time off, or a fear of not being able to work at all?(If it has NO impact at all, then write a little about that)
Self-Esteem & Confidence: How do your health issues affect your self-image and confidence? (If it has NO impact at all, then write a little about that)
Daily Functioning: How do your health issues impact your ability to perform daily tasks? (If it has NO impact at all, then write a little about that)
Peace of mind: How do your health issues make you feel anxious, worried, or uncertain about the future? In what ways do these concerns impact your daily life, emotions, and overall sense of well-being?(If it has NO impact at all, then write a little about that)
End of Program
Instructions...

1. At the START of your program - do NOT fill this section in, just scroll down and click SUBMIT.

2. At the END of your program fill this section in, and then click SUBMIT.
What changes can you SEE and FEEL in your health and well-being?
Relationships: How has the IMPROVEMENT in your HEALTH changed your relationship/activities with partner, children, grandchildren, relatives and friends?
Intimacy: How has the IMPROVEMENT in your HEALTH changed intimacy?
Work: How has the IMPROVEMENT in your HEALTH changed your ability to work? Better concentration? Less overwhelm? No time off? Confidence in being able to work?
Self-Esteem & Confidence: How is your self-image and confidence now with the IMPROVEMENT in your HEALTH?
Daily Functioning: How has the IMPROVEMENT in your HEALTH changed how you perform daily tasks?
Peace of mind: How do you feel about your future now with the IMPROVEMENT in your HEALTH?
Anything else you would like to add?
Should be Empty:

Personal Health Assessment [PHA]

HEALTH, MEDICATIONS AND SUPPLEMENTS

SLEEP

MOOD, STRESS & CONCENTRATION…

DIGESTION…

ENERGY…

SKIN, HAIR, NAILS, MOUTH…

RESPIRATORY AND CIRCULATION...

ACHES AND PAINS...

HORMONES, URINARY...

Measurements

Start of the Program

End of Program