.

Name

Email

Phone

Occupation

Average work hours/week

Height

Weight

Desired weight

Current supplements/herbs/medications

Presenting conditions/health concerns

Head
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

Best



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

Exercise

Frequency


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