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Name
*
Preferred Contact Method
Age
Pronouns
Checkboxes
Primary Care (Western/Conventional)
Naturopath
Acupuncture
Massage
Talk Therapy
Other
1. Health Concern
2. Health Concern
3. Health Concern
Share anything about how these concerns are impacting you (daily activities, habits, mood, relationships, sleep, quality of life, etc…)
What are your specific goals for working together?
else Please life,
Share anything else you want me to know about you (circumstances, concerns, preferences, or requests)
Medications (please provide date started and dosage)
Over the counter medications and supplements (please provide date started and dosage)
Do you have any current acute or chronic health conditions that you want me to be aware of?
Please check any of the following that apply or have applied in the past
Eczema
Psoriasis
Allergies
Acne
Diabetes
Lyme’s disease
Lupus
Asthma
Autoimmune Disorder
Cancer
Low Blood Pressure
High Blood Pressure
Heart Disease
Chronic Fatigue
Kidney Disease
Endometriosis
Eating disordera
Substance addiction
Cystic acne
Fibromyalgia
Multiple sclerosis
PID
Candida
Seizures
Sciatica
Herniated disc
Pneumonia
Chronic bronchitis
Diverticulitis
Crohn’s disease
Ulcerative Colitis
Gallstones
IBD
IBS
Migraines
Liver disease
Hepatitis
Intestinal Parasite
Hives
Raynaud’s syndrome
Rheumatoid Arthritis
Hernia
Hemorrhoids
Hashimotos
Hyperthyroidism
Hypothyroidism
CPTS/PTSD
Anxiety
Mania
Bipolar disorder
Depression
Herpes
HIV
Intestinal parasite
Are there any conditions not in the list above?
Please share about any major surgeries or medical interventions and when they occured here
Please share about any major health events (including injuries) and when they occured here
Family Medical History
Siezures
Arthristis
Stroke
Cancer
Heart Disease
High Blood Pressure
Diabetes
Any other family medical history you would like me to know
Allergies (environmental/seasonal, food, medications) and reaction type
Significant Recent Lab Results (Is anything out of range? Changed significantly or been brought to your attention? Please include specific results and whether results indicate a rise or fall in levels from previous bloodwork)
Dietary restrictions
Vegan
Vegetarian
Gluten
Dairy
Corn
Soy
Eggs
Nuts
Alcohol
Aster family
Nightshades
Any other dietary restrictions?
Breakfast on a typical day
Lunch on a typical day
Snack on a typical day
Dinner on a typical day
Avg cups of water per day
Avg. cups of coffee/caffeinated beverage per day
Avg. alcoholic beverages per week
Avg cigarettes per day
What kind of movement do you like to do?
Dance
Yoga
Walking/hiking
Running
HIIT
Swimming
Do you have other movement practices?
How many bowel movements do you per day on average?
Do stools tend do be hard or soft?
Very hard (rocks)
Somewhat hard
Well formed
Somewhat loose
Very loose
Diarrhea
Do you experience any of the following?
Undigested food in stool
Mucus in stool
Blood in stool
Pain with defecation
If you menstruate how long are your cycles (from first day of bleeding to the next first day of bleeding)?
Menstrual cycles regular or irregular
Often skip period
Somewhat irregular
Very consistent
Please select any that apply
Cramping before onset of bleeding
Cramping during bleeding
Clots
Chest/Breast tenderness
Depression
Fatigue
Irritability
Bloating
Night sweats
Anything else you would like to share about your feelings or experience related to menstrual cycles
Average hours of sleep per night
Difficulty sleeping?
Trouble falling asleep
Trouble staying asleep
Both trouble falling asleep and staying asleep
On a scale from 1 to 10 how much stress are you currently experiencing?
Selected Value:
0
Which of these patterns matches your experiences most closely?
Intolerance to heat
Intolerance to cold
Which of these patterns matches your experiences most closely?
Excessive tone (Constricted muscles/tissues)
Low tone (Relaxed muscles/tissues)
Which of these patterns matches your experiences most closely?
Damp (boggy/phlemy)
Dry (dehydrated tissues/brittle/cracking)
Which of these patterns matches your experiences most closely
Excited/anxious/irritated
Stagnant/depressed
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