Go ahead and fill out the questionnaire as best as you can, so we're all set for our upcoming call. Name * First Name Last Name Email * Date of Birth * MM DD YYYY Occupation Please check each condition that you are experiencing or note any family history: * General Health Callouts Abdominal pain Asthma Allergies Acne Arthritis Backache – lower/upper Cough Congestion Constipation Dry skin Dark circles under eyes Earaches Excessive urination Emotional sensitivity Eye pain/vision issues Gallstones Hearing loss High/Low blood pressure Itchy skin Indigestion Kidney stones Poor circulation Sinus infection Sore throat Ulcers Water retention Women's Health Callouts Anxiety Breast pain Breast lump Backache Endometriosis Fatigue Heavy cycles Headaches Infertility Insomnia Irregular cycles Pelvic pain Painful intercourse Painful cramps Mood swings Unusual discharge Vaginal infection Vaginal discharge Vaginal itching Movement What is your current activity level? How often do you work out? Tell me a bit about your workout routine. Cardio, weight lifting, walking, other? No detail is too small, include longevity and duration. Do you sit for prolonged periods of time? Do any activities help or worsen your pain/discomfort (emotional or physical)? Meals & Beverages Please describe your meals. What is your usual breakfast, lunch, and dinner? Get specific, what oils are you using to cook, what spices do you use, and how much of each ingredient on average are you using? Breakfast: Lunch: Dinner: How often do you consume caffeine? How much? How often do you consume alcohol? How much? Do you want to change anything about your diet? Do you follow a restricted diet? Vegetarian, Vegan, Paleo, etc.? Birth Control If birth control is your concern, what kind of birth control are you on? How long have you been on it? What BC side effects are you experiencing, if any? Emotional Are you experiencing grief? Are you experiencing anxiety? Are you able to express all of your feelings and emotions? Do you have good boundaries? Are you experiencing stress? If yes, do you know the cause? Sleep Do you sleep well? How many hours a night do you get? Do you have a consistent sleep/wake time? If yes, what times? Is it easy to wake up in the morning? Describe your general energy levels? Thank you!
