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Health History Intake Form - Part 1

Please fill this Health History form out with as much detail as you can offer. This will help me tailor this program exactly to you and your needs. Please allow up to about 30-40 minutes in total to fill out all three forms, but you can do one part, then the next later if you need. 

Click the button below to start.

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Part 1

Details & Current Concerns

Question 2 of 26

What is your:   Name,   Age,   Height    &   Current Weight?

Question 3 of 26

How did you hear about this program?

Question 4 of 26

What is your mailing address?

Question 5 of 26

Please explain your main health/fitness/body concerns and your reasons for wanting to join this program. 

Question 6 of 26

How do you hope your life will change as a result of joining this program?

Question 7 of 26

Have you had any previous or current treatment or assistance with the above concerns? If yes, please list. 

Question 8 of 26

Are you currently under treatment for any other condition, medical or other? If yes, please list. 

Question 9 of 26

How would you explain your general health?

Question 10 of 26

Are you currently on any medications or supplements? If yes, please list. 

Question 11 of 26

Do you currently follow any specific diet? Ie Vegetarian, Vegan, Gluten Free?

Question 12 of 26

Have you got any current blood test results? If yes, please upload.

If no, to pass beyond this question, you still need to upload something (tech issue), so please upload a fun photo or fun fact about you! 

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Part 2 - Detailed Past Medical History

Please outline your past medical history under each age category below including: health concerns, illnesses, accidents, toxic exposure, any pregnancies, surgeries, frequent medication use (ie antibiotics, roaccutane, contraceptive pill), any periods of high stress, and anything else you may think is relevant.  

Question 14 of 26

Detailed Past Medical History: 0-10 years of age. Including items listed above AND your birth history (natural or c-section), plus any childhood illnesses if known. 

Question 15 of 26

Detailed Past Medical History: 10-20 years of age.

Question 16 of 26

Detailed Past Medical History: 20-30 years of age.

Question 17 of 26

Detailed Past Medical History: 30-40 years of age.

Question 18 of 26

Detailed Past Medical History: 40+ years of age.

Question 19 of 26

Are there any known conditions in your family history? Ie Auto-immunity, Cancer, Heart Conditions?

Part 3

Symptoms Questionnaire

Question 21 of 26

GASTRO-INTESTINAL SYSTEM: Please tick the boxes for any symptoms that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Bloating

B

Flatulence (Wind)

C

Reflux/Heartburn/Indigestion

D

Abdominal Pain or Cramping

E

Nausea or Vomiting

F

Constipation

G

Diarrhoea

H

Straining to pass stools

I

Incomplete feeling after passing stools

J

Passing stools less than once per day

K

None of the above

Question 22 of 26

RESPIRATORY/IMMUNE SYSTEMS: Please tick the boxes for any symptoms that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Asthma

B

Shortness of Breath

C

Post Nasal Drip

D

Poor Immunity - frequent colds/flus

E

Hives

F

Cold Sores

G

Auto-Immune Disease

H

Fluid Retention (Swollen hands, ankles etc)

I

None of the above

Question 23 of 26

MENTAL/EMOTIONAL: Please tick the boxes for any symptoms that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Anxiety

B

Depression

C

High Stress

D

Busy Life

E

Feelings of overwhelm

F

Poor Memory

G

None of the above

Question 24 of 26

SKIN: Please tick the boxes for any symptoms that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Skin Rashes

B

Rosacea

C

Acne

D

Eczema or Psoriasis

E

None of the above

Question 25 of 26

HORMONE / ENDOCRINE SYSTEM: Please tick the boxes for any symptoms that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Heavy Periods

B

Hot Flushes or Night Sweats

C

Insomnia

D

Mood Changes

E

Brain Fog

F

Recent weight gain

G

Abdominal weight gain

H

Hair falling out

I

Fatigue / Poor Energy

J

Known Thyroid Disorder

K

Change in menstrual cycle

L

Period Pain

M

PMS - Pre Menstrual Symptoms (moods, teary, anxiety, irritable, food cravings, back pain, cramping, headaches, food cravings)

N

Menopause (1 year + since last period)

O

None of the above

Question 26 of 26

MUSCULO-SKELETAL SYSTEM: Please tick the boxes for any symptoms that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Headaches / Migraines

B

Muscles or Joint Pain

C

Restless legs

D

None of the above

Confirm and Submit