HEALTH HISTORY

Hey girl :) Please fill this out before our first session. Can’t wait to chat with you!

*don’t refresh the page or all progress will be lost

Name *
Name
ABOUT YOU
Relationship Status
Do you have children? *
Are you happy with your job?
GENERAL HEALTH INFO
Choose what best describes you.
Lifestyle Factors
0 = none, 10 = maxed out
0 = not at all, 10 = like a baby
choose what best describes you
PERSONAL HISTORY
NUTRITION:
GUT HEALTH
How is your digestion?
Do you experience any of the following:
DETOXIFICATION:
Are you suffering from any skin related issues:
TOXIC LOAD
HORMONES:
Do the best you can. If you are unsure, just leave blank and we can chat about it during our session.
Chocolate, Sweets and Sugar, Bread & Carbohydrates, Salty Snacky Foods, Don't really have cravings
Do you ovulate regularly?
PMS symptoms include:
Have you ever been diagnosed with PCOS?
Have you ever been diagnosed with endometriosis?
Are you peri-menopausal or menopausal?
I regularly experience:
Blood Sugar:
Do you feel better or worse after exercise?
Do you frequently experience a second wind (burst of energy) late at night?
If overweight, where is the majority of your fat stored?
EMOTIONAL HEALTH
This is a safe space. Answer in whatever way feels comfortable to you.
Can you easily express and handle feelings or emotions as they arise?
Do you do things simply for enjoyment?
Do you do things simply for enjoyment?
I regularly take care of my mental health through:
0 = not at all, 5 = very satisfied
Do you feel like your life has purpose?