Average work hours/week



Desired weight

Current supplements/herbs/medications

Presenting conditions/health concerns

HeadachesBrain fogDifficulty processing information or word lossPoor memoryDizzyness/vertigoBlurred vision

Ear, nose & throat
Post nasal dripPersistent sore throatItchy ears, tinnitus

Digestion, Gastrointestinal & Liver function
Heartburn/refluxBurpingBloating or heaviness above the bellybuttonBloating or heaviness below the bellybuttonStomach painNauseaTired after eating

Per day or week

Hard to pass, separate hard lumpsLike a sausage, smooth and softWatery, like a cow pat or explosive

Additional Information

Food cravings :YesNo

If yes, what do you crave and when

List any food allergies, sensitivities or foods that make you feel worse after eating

Immune system

Sinus or hayfever issuesPoor or delayed wound healingRecurrent infectionsUTI’s –urinary tract infectionsCold soresMouth ulcersFrequent antibiotic useHistory of viral infections, for example Glandular Fever (EBV)

Additional Information

Cardiovascular, lymphatics and circulation
Heart palpitations or diagnosed heart issuesFluid retentionNumbness or tingling in hands and feetCold hands or feetMuscle cramps, spasms or twitchesRestless legs

Additional Information

Endocrine: Female hormonal system

Periods are regular: YesNo

Average cycle length (days)

How many days of flow

Sanitary product preferences:
PadsTamponsMoon cupCombo of pads and tampons

Additional information including any previous diagnosis :

Pre-menstrual symptoms (please list)

Menopause symptoms (please list) if relevant

Endocrine: Male hormonal system

Low libidoLoss of quality of erectionsMuscle weaknessHair loss

Additional Information

Endocrine: Thyroid/Metabolic system

Weight fluctuationsFatigueDepressionDry skin (includes dandruff, cracked heals)Thinning hair & eyebrows

Additional Information

Endocrine: Adrenal energy & sleep patterns

Energy levels on average : 12345678910



Worst time of the day : MorningsMiddayAfternoonsEvenings

Best time of the day : MorningsMiddayAfternoonsEvenings

Average hours of sleep

Sleep onset – do you find it easy to get to sleep : YesNoOccasionally

Do you wake through the night : YesNoOccasionally

If yes, please describe including time of waking(s) of known:

How do you feel on waking : Mostly refreshed, bounce out of bedMostly tired and sluggishFluctuate between both

Hair, skin & nail health

Hair falling out, dry or brittleNails weak or soft, ridged or ith spotsSkin dry, sensitiveIssues with eczema or psoriasis

Additional Information

Diet & lifestyle



Water intake:

Source (tap or filtered) and how many litres per day

Coffee/caffeinated tea : YesNo

If yes, how many

Alcohol: YesNo

If yes, what type, For example wine, beer, spirits

How many drinks per session?

How many sessions per week?

Tobacco/smoking : No, neverNo, but have a past historyYes, currently

Additional Information

Chemical exposure (please list known sources; work, home, personal care products include hair colouring, radiation or environmental)

Do you feel particularly sensitive or have an aversion to smells, fumes, perfumes of a chemical nature? : YesNo

Stressors: Mental & Emotional :

How do you respond to stress and process your emotions:
Internalise (don’t deal with it)Reactive (outbursts)Use substances (alcohol, smoking. other)Emotionally (unconsciously eat)ExerciseJournal/dairyTeary (cry at the drop of a hat)MeditateTalk it out

Please describe your biggest sources/triggers/contributors for stress

Anxiety (constant worry, inability to switch off, busy mentally, panic attacks) : YesNoOccasionallyPast history

Please describe when this is most relevant

Depression (low mood, low motivation, sadness, tearful, negative thoughts, addiction) :YesNoOccasionallyPast history

Please describe when this is most relevant

I feel easily frustrated, irritable, low tolerance for people or snappy : YesNoOccasionallyPast history

Please describe when this is most relevant

Thank you for filling out this very detailed form, I look forward to working with you

Kind regards,

Laurel Hefferon