Intake

Describe your main symptoms, health challenges, or reason for joining this coaching program. *

If there was one main issue that you could prioritize as part of your healing, what would it be? *

What treatments have you tried already, if any? *

Have any other treatments/approaches been successful for you? If so, please describe. *

Include any other details about your symptoms that you'd like to share. *

Home & Family life

Do you have any children? If so, how many and how old are they? *

Do you have pets or animals living in the house? *

Have there been any major changes in your home life recently? If so, please describe. *

Would you consider your home a safe and relaxing place to be? *

Have you experienced any traumatic losses in your life? (death, break-ups, job loss, etc) *

Did you eat a lot of sugar and processed food growing up? *

Is there anything else relating to you childhood or family life that you'd like to share? *

Work & Livelihood

Do you consider yourself financially stable? *

Have you been fired or laid off in the past year? *

How many hours a week do you typically spend working? *

Is there anything else related to your work situation that you'd like to share? *

Relationship

Are you currently involved in a romantic partnership, domestic or otherwise? *

If in partnership, how long have you been together? *

How would you describe the health and stability of your current relationship? *

Do you feel valued and respected in your current relationship? *

Is there anything else related to your relationship that you'd like to share? *

Trauma

I understand that some of these questions can be sensitive or emotionally triggering. You are not required to answer these questions here, and if you feel more conformably discussing these questions in private, please let me know.

Did you experience physical or emotional abuse growing up? *

Was alcohol or drug use common in your childhood environment? *

Did you feel you were properly cared for growing up? *

Have you witnessed or experienced any violent or otherwise traumatic experiences in your life? *

Is there anything else related to traumatic experiences that you'd like to share? *

Medical History

Please describe your medical and/or surgical history including previous or current diagnosis. *

How often do you take NSAID's like Advil, Ibuprofen, Midol, Aleve, Nuprin? *

What prescription or over-the-counter medications, if any, are you taking now? *

Please list all vitamins, minerals, and herbal supplements you are currently taking. *

Did your parents or siblings have any serious health issues? *

Diet & Digestion

Walk me through a typical day for you in terms of diet from the time you wake up until the time you go to bed. Be as detailed as possible, including beverages and meal times. *

Do you typically drink water from the tap, filter, or spring? *

Do you have any known food allergies? If so, what are they? *

Are you on any special diet? (Keto, Paleo, low carb, Carnivore, Vegan, Vegetarian, Fruitarian, etc) *

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? *

Do you feel much worse when you eat certain foods? *

Do you feel much better when you eat certain foods? *

Do you feel better or worse when you skip a meal? *

Is there a certain food that you really crave or love to binge on? *

Do you have a strong aversion to certain foods? *

Have many bowel movements do you have per day? *

Is there anything else related to diet & digestion that you'd like to share? *

Toxin Exposure

Do you smoke tobacco? If so, how much and for how long have you smoked? *

Do you use any other substances, entheogen, or plant medicines? *

Would you describe yourself as having any substance (natural or synthetic) addictions? If so, please describe. *

Do you have mercury amalgam fillings in your teeth? If so, how many? *

Do you have any artificial joints or implants? If so, which ones. *

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

Do you use cosmetics, antiperspirants, shampoo/soaps/conditioners? If so, please describe. *

What percentage of the food you eat is organic? *

0-25% 25-50% 50-75% 75-100%

Stress

On a scale of 1-10, where would you rate your current average stress level? (10 being extremely stressed) *

Have you ever undergone counseling? If so, what kind and did you find it helpful? *

Do you often worry about the future, or regret things from the past? If so, please describe. *

Do you have any hobbies or leisure activities? If so, please describe *

Sleep

How many hours do you sleep per night on average? *

Do you have any trouble falling asleep and/or staying asleep? *

What time do you typically get to bed and wake up each day? *

Do you find yourself feeling rested or tired during your waking hours? *

Exercise

How many times a week to do get some form of exercise? *

0 1-3 4-6 7-9

Please describe your current workout routine if applicable. *

Do you have any spiritual beliefs and/or practices? *

Please take your time to fill out this health intake form honestly, and to the best of your ability.