Name
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First Name
Last Name
Email
How did you hear about this work
Current Gender identity with pronouns & Sex at birth
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Primary reason for vist
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What are you hoping to achieve?
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When did you first notice this & what may of triggered it?
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Describe any stressors at this time
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What makes you feel better & what makes you feel worse?
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What changes or goals would you like to see in the next 3-6 months?
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Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:
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Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?
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Do you smoke? If so, how regularly and how do you feel about this?
Any allergies? If yes, what are you allergic to? What reaction do you have?
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Have you experienced any of the following, surgeries, accidents, injuries to head or tailbone? If so, please share some details.
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Do you experience any of the following?
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Please further describe any boxes checked above
Maternal
Paternal
Please describe your relationship with food
Do you follow a particular diet?
Food intolerances or allergies?
What are meal times like?
Do you eat home cooked meals
What is your daily intake like for water, caffeine and alcohol?
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Do you experience bloating, belching or gas after eating? What triggers this?
How often are your bowel movements?
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Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?
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How do you nurture yourself?
Are you currently experiencing stress? If so how to you manage it?
Do you have a faith or spiritual practice and if so, would you be willing to share this?
Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?
