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Health History Intake Form - Part 2

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 4

Lifestyle Factors

Question 2 of 14

 Please tick any that apply to you.

(Select all that apply)
A

Smoker

B

Recreational drug use (current or in past)

C

Use of Bleach or Ammonia (cleaning products)

D

Large amounts of plane travel

E

Pesticide / Herbicide exposure (frequently)

F

Non-organic or not-natural beauty products and make-up

G

Sensitivity to Perfumes, Odors, Fumes

H

Dust allergy

I

Grasses / Pollen allergy or Hayfever

J

Mould Sensitivity

K

None of the above

Question 3 of 14

If any, what Exercise do you currently do? List each type, and how often you exercise.

Question 4 of 14

SLEEP: What time do you go to bed at night? What time do you wake in the mornings? Do you wake overnight night? 

Part 5

Food & Nutrition

Question 6 of 14

FOOD INTOLERANCES: Please tick the boxes for any food intolerances that you are currently experiencing, or have regularly experienced in the past 3 months. 

(Select all that apply)
A

Dairy

B

Wheat or Gluten

C

Sugar

D

Eggs

E

Citrus

F

Coffee

G

Alcohol

H

Fatty Foods

I

Spicy Foods

J

Other (I'll ask you more about this in our 1:1 appointment)

K

None of the above

Question 7 of 14

BREAKFAST: Please outline what foods you typically eat for Breakfast.  Also please tell me what time you typically eat Breakfast. 

Question 8 of 14

LUNCH: Please outline what foods you typically eat for Lunch.  Also please tell me what time you typically eat Lunch. 

Question 9 of 14

DINNER: Please outline what foods you typically eat for Dinner.  Also please tell me what time you typically eat Dinner. 

Question 10 of 14

SNACKS: Please outline what foods you typically eat for Snacks. 

Question 11 of 14

Do you get any regular cravings? If yes, please outline. 

Question 12 of 14

Do you drink coffee? If yes, how often, and what times of the day?

Question 13 of 14

Do you drink alcohol? If yes, how much, when, and what type?

Question 14 of 14

How much water or herbal teas do you drink?

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