Integrative Wellness Testing/Coaching Form Name * First Name Last Name D.O.B. Height Weight Address Phone (###) ### #### Email Receive appointment reminders via Email Text Emergency Contact How did you hear about us? Please list any questions or concerns that you have and the reason for your visit Please list all medications and supplements you are currently taking Have you been under the care of a physician or other medical professional within the past year? Any recent surgery, including plastic surgery? If yes, explain. Have you had any of the following health conditions in the past, or present? Cancer Hormone Imbalance High/Low blood pressure Hysterectomy Arthritis Thyroid Disease Diabetes Skin diseases/lesions Insomnia Crohn's/Colitis Headaches Hepatitas Heart problems Varicose Veins Asthma Epilepsy Immune disorders Poor circulation Eczema HIV/AIDS Do you smoke? Do you follow a restricted diet? Have you ever had an allergic reaction? Are you taking any oral contraceptives? Are you trying to become pregnant? Vitamin/Mineral Deficiencies Any active infections Menopause problems What is the date of your last menstrual period? What is your stress level? High Medium Low Any food/chemical sensitivity in the last 60 days? Stomach Pain/Cramping Constipation Diarrhea Reflux/Heartburn Bloating/Gas Nausea/Vomiting Inability to lose/gain weight Food/Sugar cravings Binge Eating Water Retention Stuffy or runny nose Asthma Chest congestion Chronic cough Wheezing Frequent sneezing Migraines Headaches Earaches/Infection Ringing in ears Itchy/Watery eyes Sore throat Persistent canker sore Depression Anxiety Mood swings Irritability Poor concentration Fatigue/Lethargy Hyperactivity Restlessness Insomnia Eczema Dermatitis Excessive sweating Rashes Hives Joint pain Arthritis Muscle aches Irregular heartbeat Basic Hormone Imbalance-Female Hot flashes Heart palpitations Heavy menses Fibrocystic breasts Thinning skin Mood swings Cystic ovaries Foggy thinking Irritability Uterine fibroids Urinary incontinence Vaginal dryness Weight gain Increased body/facial hair Night sweats Acne Depressed mood Headaches Bone loss Adrenal Hormonal Imbalance-Female Aches and pains Sleep disturbances Infertility Chronic illness Elevated triglycerides Depression Nervousness Evening fatigue Morning fatigue Anxiety Allergic conditions Bone loss Susceptibility to infections Blood sugar imbalance Autoimmune illness Thyroid Hormone Imbalance-Female Aches and pains Dry skin Fatigue Heart palpitations Constipation Anxiety Cold hands and feet Foggy thinking Low libido Thinning hair Brittle nails Headaches Weight gain/Inability to lose Elevated cholesterol Menstrual irregularities Depression Infertility Feeling cold all of the time Sleep disturbances Basic Hormone Imbalance-Male Burnt out feeling Hot flashes Weight gain in waist Decreased libido Decreased erections Night sweats Irritable Erectile dysfunction Prostate problems Decreased mental sharpness Insomnia Increased urinary urge Infertility problems Oily skin Apathy Decreased urine flow Decreased stamina Sleep disturbances Decreased muscle mass Adrenal Hormonal Imbalance-Male Aches and pains Sleep disturbances Infertility Bond loss Stress Elevated triglycerides Depression Lack of motivation Prostate problems Evening fatigue Morning fatigue Anxiety Allergic conditions Weight gain in waist Decreased erections Fibromyalgia Blood sugar imbalance Autoimmune illness Chronic illness/Susceptible to infections Thyroid Hormone Imbalance-Male Low libido Foggy thinking Constipation Fatigue Elevated cholesterol Depression Infertility Cold body temperature Headaches Lack of motivation Decreased erections Sleep disturbances Inability to lose weight Thank you!
