Date *
Date
Name *
Name
Phone *
Phone
Please describe any lifestyle goals that you would like to manifest + cultivate.
Give me an idea of your daily nourishment. Please keep track + provide me with a 3 day diary (you can email me separately). Include the times you eat, how you hydrate + how much, along with any restrictions, allergies + sensitivities.
Please include your workout routines, meditation + ritual practice, sleeping habits, + favorite hobbies. Share with me what you LOVE to do.
Please rate the level of stress that you are experiencing on a daily basis from 1 - 10. Identify the major causes of this stress (job, residence, financial, relationship, health, legal, other).
Tell me a bit about your current state of health. Severe illness? Energy levels? Any fatigue? Depression? Anxiety? Insomnia? Hormone imbalances? Addictions?
Please describe any traumas to your body - surgeries, injuries, hospitalizations, scars. Include dates.
Bowel Movements :: How often do you have them? What is the consistency, color, length? What time/s of day? Do you struggle to go? Any stomach issues? Pain or aches? Indigestion/Heartburn/Gas/Bloating? Have you ever been diagnosed with Candida or Leaky Gut?
Describe your sleep habits. What time do you go to sleep and wake in the morning? Do you have trouble falling asleep? Do you wake up in the night? If so, what time? Do you sweat throughout the night? Do you tend to have excess energy before bed?
Please list all medications including dosage and times that you take. Have you ever taken antibiotics? If so, when and for how long?
Please list all supplements that you are currently taking. Include vitamins, herbs, flower essences, superfoods, etc.
What other healing modalities have you tried? Are you currently working with any other healing practitioners?