Holistic Health Assessment

Location of Birth (City, Country)*

Where have you lived throughout your life?*

What is your cultural or ancestral background?*

Typical hours worked per week*

Relationship status (optional)

Do you have children or dependents? (optional)

What are your primary health concerns?*

was happening in your life when these concerns first began?*

How much do these concerns affect your daily life?*

What do you hope to experience differently as a result of working together? And why now?*

Any major illnesses or surgeries or hospitalizations in the past?*

Any known digestive diagnoses? (IBS, SIBO, GERD, Crohn's, etc.)*

Current medications, supplements, or recreational substances:*

Have you had any recent bloodwork, imaging, or specialist assessments related to your health concerns?*

If yes: Please briefly describe the results or findings.

Are there any hormonal or reproductive health changes that feel relevant to your current health? (Examples: menstrual cycle changes, fertility, pregnancy, postpartum, perimenopause, menopause, PCOS, endometriosis, etc.)

Do any of the following conditions run in your family? (Select all that apply.)

If other, please describe

Digestion*

Energy & Vitality*

Temperature & Circulation*

Skin & Hair*

Muscles & Joints*

Mind & Emotions*

Body Type*

Appetite*

Energy*

Sleep*

Temperament Preference*

Skin*

How is your appetite CURRENTLY?*

Do you feel true hunger before meals, or do you often eat out of routine or habit?*

How do you typically feel after eating? (Select all that apply.)*

When do your digestive symptoms usually occur?*

Have you noticed any foods that consistently aggravate your digestion?*

How often do you have a bowel movement?*

What time of day do you usually have a bowel movement?*

Which best describes your stool most often?*

Do you regularly experience any of the following?*

Do you generally feel complete relief after a bowel movement?*

When do you feel your digestion is at its best?*

When do you feel it is at its worst?*

What have you already tried to support your digestion?*

Have you noticed anything that seems to trigger or worsen your symptoms?*

When you look at your tongue in the morning, what do you notice most?*

Do you regularly notice any of the following?*

Do you regularly experience any of the following?*

Time you usually wake*

Time you usually go to sleep*

On average, how many hours of sleep do you get each night?*

Do you fall asleep easily?*

Do you wake during the night?*

How do you usually feel upon waking?*

What time do you typically eat breakfast, lunch, and dinner?*

Do you tend to eat meals at regular times each day?*

How many meals do you usually eat each day?*

How quickly do you eat?*

Do you snack between meals?*

While eating, do you usually:*

Do you often eat when:*

Do you regularly experience any of the following? (Select all that apply.)*

How much movement or exercise do you typically get each week?*

What types of movement do you enjoy or practice regularly?*

Do you spend time outdoors regularly?*

How would you describe your daily routine?*

What best describes your work?*

Do you feel you have time for rest and relaxation?*

Walk me through a typical day of eating. Please include approximate meal times, snacks, and beverages.*

Approximately what percentage of your meals are: Home-cooked, Take-out / restaurant, Packaged / convenience foods *

How often do you consume coffee or caffeinated beverages?

How often do you consume alcohol?*

How often do you consume sugary foods or drinks?*

How often do you consume processed or packaged foods?*

How would you describe your thirst?*

How much water do you typically drink each day?*

Do you prefer:*

Do you drink liquids:*

How would you describe your energy throughout the day?*

When is your energy usually at its best?*

When is your energy usually at its lowest?*

Which of the following do you experience regularly? (Select all that apply.)*

Do your physical symptoms tend to worsen during periods of stress?*

Do your digestive symptoms worsen during stress?*

What are the biggest sources of stress in your life right now?*

How well do you feel you're able to recover from stress?*

Overall, how would you describe your current vitality?*

When was the last time you remember feeling truly healthy and well?*

What was different about your life during that time?*

What do you feel your body has been asking for lately?*