Consultation Background Intake Let’s get you ready for our consultation Before the consultation at least 48 hours, you will need to complete THIS FORM. This information will enable me to give a thorough and quality consultation.You are encouraged to attach any relevant labs and clinical information. Conscious Consultation Background Name * First Name Last Name Email * Date of Birth * MM DD YYYY Time of Birth * Hour Minute Second AM PM Birth Location (City, State, Country) * Gender * Male Female Other Top 3 Health Complaints * Or areas in your wellness you'd like to improve What is your life purpose or health mantra you live your life by? * Something you can say to yourself daily - keeps you going. i.e. "My body is a vessel of wellness. It does hard work to make me strong in all ways. Today I will focus on what makes me feel good. I am a healthy and happy person." Quick health history summary. * Please include past medical history, surgeries. List any relevant exposures or life events, genetic concerns, or anything most pertinent to wellness concerns. Giving as much detail as possible. Tell me about your current diet * Please include how many meals per day (general meal contents, if you have macros/calories you follow please include), times of when you eat (first and last meal most important to know timing of), amount of fluid intake (amount and what kind), caffeine intake (when and how much), alcohol intake (type and drinks/week). Eating Habits * If you eat 21 meals per week (3 meals daily; or describe meals per day/week), how many are home cooked, store bought, or out to eat (restaurant and fast foods). What are you doing when you are eating? (sitting with family, in front of computer, sitting/standing, watching TV). How quickly do you finish your meals (timeline). Caffeine Use * Describe your caffeine use. Type (coffee, tea, drinks, supplements), amount (mg/day if possible), when during the day (morning, mid morning, afternoon, evening), purpose (wake up, before workouts), habits (how often, increasing, cutting back). Do you feel energized versus stimulated? Attachment to coffee/caffeine scale of 1-10 (10 = can't live without) Bowel Habits * Describe your bowel habits: How many per day, consistency. Describe your gas/bloating if any (scent and degree of discomfort with bloating). How is your exercise regimen? * Current exercise regimen; type and how often (time spent doing activity and how often per week) If limited/none, tell me what you do like to do for physical activity. What if anything has or hasn't worked well in the past? How's your sleep? * Current sleep; describe your sleep. Tracking sleep, time you go to bed/wake up, different over weekends, average hours asleep, non-sleep related activities (watching TV, working, eating, reading), barriers to better sleeping habits, what have you tried. Describe what if any sunlight you are expose to during the day. FEMALE ONLY: How's your menstrual cycle? If you're tracking cycle please describe: Tracking method, cycle length, menstrual length with flow/volume/content description, cycle symptoms, concerns. Do you take any prescription medications? * List supplements (what were they recommended for)? Include dose, formulation and brand (supplements). A full medication list can be sent directly to me if necessary. If you had a magic wand to "cure" your overall health / life concern(s), what would those be? * Rate your motivation level to make the changes in your life big/small for the betterment of your health / life? and why * 1 - Very Low 2 3 4 5- Indifferent 6 7 8 9 10 - Very High Have you been recommended any plans/treatments in the past? * What has or hasn't worked in the past for your wellness concerns (if anything). Any other things you like to add or let me know about!? * Send me a copy of my responses. * Yes No Thank you!
