Emergency Contact

General medical

Personal medical history *

Please list past medical conditions and hospitalizations

Family history *

Please list medical conditions in the family including: siblings, parents, and grandparents.

Allergies

Please list all allergies past and present

Smoking and Recreational drugs *

Medications and supplements *

List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.

Review of Systems

Symptoms (other)

Please list any other symptoms or health concerns not listed above that you have currently experienced whether they seem related or not to your present chief health concern(s).

Bowel movements *

Stool appearance *

Please select usual appearance

Urine *

Usual appearance of urine Other

Colds *

Do you get colds, runny noses, and flus easily?

Headaches

Do you get frequent headaches

Menstruation

Menstrual cycle length

How long is your typical cycle?

Description of flow

Description of menstrual flow (color, volume, etc)

Menstrual regularity

Are your cycles regular?

Diet & Nutrition

Diet category *

Omnivore (no restrictions)

Pescetarian (fish and chicken)

Vegetarian (includes eggs and milk)

Vegan

Paleolithic / Ketogenic

Other

Meal times *

My typical times for breakfast, lunch, and dinner are? Include snack times

I eat fruit *

I eat vegetables *

My grains are *

I eat grains *

Types of oil I use *

Click all that applies

Canola

Olive

Coconut

Grapeseed

Vegetable

Other

I use oil for *

Stir frying

Deep frying

Baking

Seasonings, dressings

Other

I enjoy fried foods *

I eat nuts *

I eat beans

I eat meat *

I eat dairy products *

Snack foods I enjoy are

I eat out *

I drink water *

Cups of coffee per day *

Cups of tea per day *

I drink juices *

I drink fluids with my meals *

I drink alcohol *

Physical Activity & Exercise

Frequency of physical activity *

How many days a week are you doing structured physical activity?

Current physical activities *

Please share with us what types of exercise activities you are currently engaged in

Activity preferences

Please list any activities you would like to explore and also activities you absolutely dislike doing.

Equipment available at home are

Click all that apply

dumb bells

barbells + weights

resistance bands

kettle bells

stability balls (yoga ball)

Medicine ball

treadmill

stationary bike

elliptical

none

How do you travel to and from work? *

Transit

Vehicle

Walk

Biking

Other

Gym membership

Barriers to physical activity

List if any

Sleep & Sunlight

Direct sunlight each day? *

Typical hours of sleep each night *

I feel well rested after sleeping *

Bed time and wake time *

When do you typically go to bed and when do you usually wake up?

Time to fall asleep *

Wake up in the middle of the night? *

Mood & Emotions

Worry *

Over the last 2 weeks, have you experienced any of the following symptoms?

Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

None

Mood *

Over the last 2 weeks, have you experienced any of the following problems?

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling/staying asleep, sleeping too much

Feeling tired or having little energy

Poor appetitie or overeating

Feeling bad about yourself, or that you are a failure, or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching TV

Moving or speaking slowly that other people have noticed. Or the opposite; being so fidgety or restless that you have been moving around more than usual.

Thoughts that you would be better off dead or off hurting yourself in some way.

None

Rate your stress out of 10

1 = No stress 10 = Extremely stressed

1

2

3

4

5

6

7

8

9

10

Rate your energy out of 10

1 = Absolutely no energy 10 = Full of energy

1

2

3

4

5

6

7

8

9

10

Miscellaneous

Would you like to be added to our emailing list for clinic updates, promotions, and health information?

Best method of contact

Phone

Email

Comments

Please indicate any other comments you feel are necessary for us when considering your case