Legal Name
First Name
Last Name
Preferred Name or Nicknames
Preferred Pronouns
Date of Birth
Email
*
Phone
(###)
###
####
Mailing Address
Emergency Contact
First Name
Last Name
Emergency Contact Phone
(###)
###
####
In 2-3 sentences please share the concern/s that prompted this consultation?
Please list your additional pressing health concerns or goals
Phone
(###)
###
####
Address
Gastrointestinal
How often do you have a bowel movement?
Which best describes your stools?
Check all that apply
Do you have difficulty or pain associated with passing a bowel movement?
If your bowels are disturbed do you tend to:
Have you ever had a colonscopy?
Use this space to provide details (including onset dates) about any condition you check above or list other gastrointestinal conditions:
Respiratory
Use this space to provide details (including onset dates) about any condition you check above or list other respiratory conditions:
Musculoskeletal/Pain/AutoImmune
Use this space to provide details (including onset dates) about any condition you check above or list other musculoskeletal or inflammatory or auto immune conditions:
Neurological and Mental Health
Use this space to provide details (including onset dates) about any condition you check above or list other neurological or mental health conditions:
Blood and Cardiovascular Health
Use this space to provide details (including onset dates) about any condition you check above or list other blood or cardivascular conditions:
Urinary and Gynecological Health
Sexual Health
Do you experience any of the following?
Are you currently trying to conceive?
Use this space to provide details (including onset dates) about any condition you check above or list other urinary or gynecological conditions:
Cancer
Please specify with cancer type and treatment and diagnose dates:
Metabolic and Endocrine Health
Use this space to provide details (including onset dates) about any condition you check above or list other metabolic and endocrine conditions:
Dermatological Health
Use this space to provide details (including onset dates) about any condition you check above or list other dermatological conditions:
Do you visit a dentist regularly?
Twice per year?
Do you brush and floss regularly?
Do you have any of the following?
Check all that apply
Is this section relevant for you?
Check yes if you currently menstruate or used to menstruate
Are you now or have you ever been pregnant
Pregancies
List pregnancies, date and outcome by specifying: vaginal, c-section, loss or terminated (if you are comfortable doing so)
Are you currently in your menstrual years?
Check yes if you are between puberty and menopause
Are you ovulating regularly? How do you know?
Do you experience any of the following related to your menstrual cycle?
Would you consider your flow on your heaviest day to be:
What type(s) of birth control are you using (if relevant)?
Are you currently lactating?
Are you currently peri- or post-menopausal?
Do you experience any of the following?
Your birth:
How would you rate your health as a child?
Please describe any health challenges or significant experiences from childhood.
Mother:
Father:
Siblings:
Grandparents:
Known genetic disorders:
Additional family history:
Racial/Ethnic Background
If other, please specify:
Do you experience any food, environmental, seasonal or other allergies
Please describe any allergies, including the substances to which you are allergic and any symptoms you experience.
Prescription and OTC medications:
Vitamins, supplements and minerals:
Have you had prolonged or regular use of NSAIDs (Advil. Aleve, etc.), Motrin, or Aspirin?
Have you had prolonged or regular use of Tylenol?
Have you had prolonged or regular use of opiod pain killers?
Have you had prolonged or regular use of proton pump inhibitors (PPI) or acid-blocking drugs?
Frequent antibiotic use? (> 3 times per year)
Long-term antibiotic use?
Please list any previous injuries, surgeries, and hospitalizations; provide the date and your age, if known.
Please list any recent lab work or diagnostic studies that you'd like to bring to my attention.
Have you ever had a nutrition consultation?
Have you made any changes to your eating habits because of your health?
Do you currently follow a special diet or nutritional program?
If yes, what diet?
Please describe your typcal daily diet and a typical days worth of meals:
How would you rate the quality of your diet over the past month?
How many servings of fruit and/or vegetables do you eat in a day?
What are your comfort foods?
Height:
Current weight:
Usual weight:
Desired/goal weight:
Weight 1 year ago:
Have you recently lost or gained a significant amount of weight?
Do you have a history of dieting?
In other words, have you repeatedly followed one or more diets for weight loss or health?
Do your currently have or are you recovering from an eating disorder?
Caffeinated beverage
Coffee, caffeinated tea or energy drinks
Soda
Juice
Alcohol
Beer, wine cider or hard liquor
Animal Milk
Cow or goat milk
How many 8 oz glasses of water do you drink per day?
Do you filter the water in your house?
Check all of the following that apply:
What questions do you have about your nutrition or eating patterns?
When was the last time you felt well?
With whom do you live?
Include, pets, children, roomates, partner/spouse
Are you satisfied with your current living situation?
Do you engage in moderate physical activity for 20+ mins on 3+ days per week?
Please list exercises/physical activities and frequency:
ie Yoga 30 mins 2 times/week
Do you have any issues or conditions that limit your physical activity? Please describe.
Do you smoke or chew tobacco
Do you smoke or use marijuana?
Are you exposed to second hand smoke?
Do you currently use psilocybin, cocaine, heroin, speed, LSD, etc?
Which describe(s) your current employment status?
Check all that apply
Where do you work or study?
Which of the following contribute to current or frequent stress in your life?
Check all that apply.
Have you experienced any particularly stressful event(s) in the past 10 years?
May include death of a family member or friend, loss of job or home, moving, pregnancy loss, illness
What do you do do relieve stress and/or relax?
What are your creative outlets or what do you do for fun?
Do you have a spiritual practice?
If yes, do you feel satisfied with your spirituality and safe to express it?
How many hours do you sleep per night, on average?
Do you have trouble falling asleep?
Do you feel rested when you wake?
Do you wake up at night?
Do you use anything to help you fall or stay asleep?
How would you rate the overall quality of your sleep?
Do you experience or have you been diagnosed with chemical sensitivities?
Are you exposed regularly to any of the following:
If you had to guess, what two changes could you make now that would make the most difference in the way you feel?
As part of our work together, what are you interested in?
Check all that apply.
How often do you anticipate needing/wanting to schedule appointments?
When it comes to herbs/supplements:
Check all that apply.
Which of the following are you willing to do in order to improve your health?
Check all that apply
What excites you most about us working together?
Is there anything that concerns you, makes you nervous or anything you believe may get in the way of us working together?
Is there anything else you would like to share that hasn't been asked?
