Questionnaire

Congratulations 🎉

You're about to take the first step toward truly understanding what your body needs to restore balance, achieve homeostasis, and move toward full, vibrant health. Please take a few moments to thoughtfully answer all the questions below. When you’re finished, simply click the "SUBMIT" button at the bottom of the form. As soon as I receive your completed form, I’ll personally review your responses, begin creating a personalized plan for you, and reach out to schedule your Zoom consultation. I’m excited to work with you and support you on this powerful journey!

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Name *

First

Last

Date of Birth *

Blood Type (if known) *

On a scale of 1 - 10 how do you rate your health and vitality right now? (1 being flat on your back, 10 being walking on air). *

Email *

Weight (Kgs) *

Time Testing Carried out *

Are you on any medications? If so, please note here ... *

On a scale of between 1 an 10 (1 being very poor and 10 being excellent), how would you rate your current emotional wellbeing? *

Pre-existing conditions

Please list any pre-existing health conditions, health concerns, symptoms or any other relevant information that might be of help with this assessment *

Questionnaire

Do you suffer from vertigo (a specific kind of dizziness - a sense that you, or your environment, is moving or spinning, even though there is no movement)? *

Do you suffer from depression? *

Do you suffer from general fatigue? *

Do you suffer from insomnia? *

Do you have cravings? *

Do you suffer cramps? *

Do you suffer hypertension? *

Do you have poor circulation? *

Do you suffer cardiovascular disease? *

Do you normally have a high body temperature? *

Do you have polyuria (excessive or abnormally large production or passage of urine)? *

Do you find it hard to wake up in the morning? *

Do you suffer from anxiety? *

Do you normally have a low body temperature? *

Do you have olyguria (low output of urine)? *

Do you often have soft / loose stools? *

Do wake up in the morning easily? *

Are you slow to heal? *

Do you get migraines? *

Do you suffer from muscle loss? *

Do you suffer from weight issues? *

Do you get irritable when hungry? *

Do you have type II diabetes? *

Are your hands normally warm and dry? *

Are your fingers warmer than your triceps? *

Do you suffer from asthma? *

Do you suffer from allergies (not food)? *

Are your hands normally cold? *

Are your fingers colder than your triceps? *

Is your mouth normally dry? *

Do you suffer from food allergies? *

Do you suffer from shortness of breath? *

Do you suffer from chronic fatigue? *

Do you suffer from sleep apnea? *

Do you normally suffer from Osteoarthritis? *

Do you normally suffer from Rheumatoid Arthritis? *

Do you frequently pass gas after meals? *

Do you suffer from reflux or heartburn? *

Do you often burp after meals or feel bloated? (Even just small burps.)? *

Does your meal ever feel like it's sitting in your stomach like a rock for too long? *

Do you crave sweet or salty foods? *

Do some foods make you nauseous? *

Is your stool sometimes lighter than the colour of corrugated cardboard? *

Do you have regular (daily) bowel movements? *

How many bowel movements do you have on a typical day? *

Do you ever experience heartburn or acid reflux? *

Have you recently taken any antacids or acid reflux medications? *

Are you frequently constipated? *

Do you frequently experience diarrhoea? *

Do you have a stomach ulcer? *

Have you had your gallbladder removed? *

Do you ever see undigested food in your stool? *

Do you seem to gain weight no matter what you eat? *

Do cravings frequently derail your weight loss attempts? *

Approximately how many litres of water do you drink per day (not including coffee / tea / soft drinks etc? *

Do you drink coffee regularly? *

Do you drink alcohol on a regular basis? *

Do you smoke tobacco? *

How much salt do you normally add to your food or water each day? *

What type of salt do you normally use (normal table salt / Celtic sea salt / Himalayan pink salt etc.) *

Do you take recreational drugs? *

Do you normally drink water / alcohol / other drinks with your meals? *

What is normally your first drink of the day? *

Do you normally drink your first drink of the day before you eat any food? *

Please list any other drinks you would normally drink each day *

How many hours of sleep on average do you get each night? *

How often do you exercise? *

What type of exercise do you do? *

Please list any supplements you are taking and why you are taking them. *

Do you normally eat breakfast? *

Please list foods you would normally eat for breakfast? *

Do you normally eat lunch? *

Please list foods you would normally eat for lunch *

Do you normally eat tea / evening dinner? *

Please list foods you would normally eat for tea / evening dinner? *

Do you normally eat supper? *

Please list foods you would normally eat for supper *

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