Tell me a little about yourself! This will help me get a better understanding before we meet. Name * First Name Last Name Email * Subject * Phone * (###) ### #### Age * Height & Weight (optional) Health Overview Do you have any current medical diagnoses or conditions? * Are you currently on any medications? * Yes No If yes, please list them: * Do you take any supplements? * Yes No If yes, please list them and your typical dosage: Have you had recent bloodwork done? * Yes, within the last 3 months Yes, within the last 6 months Over 6 months ago Not yet Have you worked with a holistic or functional practitioner before? * Yes No If yes, what was your experience like? Lifestyle & Nutrition Describe a typical day of eating for you (include meals/snacks if possible): * Do you have any food sensitivities, allergies, or dislikes? * How often do you cook meals at home? * Daily A few times a week Rarely Sleep, Stress & Movement How would you describe your sleep? * I fall asleep easily and sleep through the night I have trouble falling asleep I wake up during the night I wake up feeling tired What time do you typically go to bed and wake up? * How would you rate your current stress levels? Low Moderate High Overwhelming How do you usually cope with stress? * Do you engage in any movement or exercise? * Yes, regularly Sometimes Rarely If yes, what type and how often? Hormone & Cycle Check-In Do you currently have a menstrual cycle? * Yes No Irregular Pregnant Postpartum Perimenopausal Menopausal Do you track your cycle? * Yes No If yes, how? (e.g. app, calendar, temp, symptoms) * How would you describe your periods? * Light Moderate Heavy Painful Irregular With clots Spotting between periods No period at all Hormone Symptom Check-In * Mood swings or irritability before my period Breast tenderness or swelling Heavy bleeding or clots Gain weight easily around hips or belly Often cold (hands/feet) Hair thinning and/or outer eyebrow loss Tired in the morning even after sleep Feel wired but tired at night Trouble falling or staying asleep Feel anxious, foggy, or emotionally drained Crave sugar or carbs, especially late afternoon Feel tired or crash after meals Shaky or irritable if meals are delayed Constipated or slow digestion Extra belly fat that’s hard to lose Night Sweats Difficulty losing weight Gut & Detox How often do you have a bowel movement? * More than once a day Daily Every 2–3 days Less often What best describes your digestion? * Regular and normal Occasional bloating Frequent bloating/gas Constipation Loose stools/diarrhea Any history of antibiotics, food poisoning, or stomach bugs? * Almost Done! Is there anything else you’d like me to know about your health, goals, or challenges? * Thank you! Please fill out this form before our discovery call
