Please complete this questionnaire as thoroughly as possible. There are no “right” or “wrong” answers — this simply helps me better understand your body, symptoms, patterns, and areas that may need support. For each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantBasic InformationNameDateToday’s DateAgeRelationship StatusOccupationChildren/PregnanciesCurrent GoalsWhat are your main health goals right now?What do you feel is your biggest struggle currently?How do you learn best?Reading/WritingVisualAuditoryHands OnOtherWhat best motivates you?Are you more extroverted or introverted?ExtrovertedIntrovertedOtherEnergy + Nervous SystemFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantFatigueAfternoon energy crashBurnoutFeeling wired but tiredIrritabilityDifficulty relaxingAnxietyMood swingsDepression/low moodTrouble concentratingBrain fogFeeling overwhelmed easilyDizziness/lightheadednessSleepFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantDifficulty falling asleepWaking during the nightWaking too earlyRestless sleepNight sweatsFeeling unrefreshed in the morningDependence on caffeineDigestion + Gut HealthFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantBloatingGasConstipationDiarrheaAlternating constipation/diarrheaAcid reflux/heartburnNauseaFood sensitivitiesStomach pain/crampingFeeling overly full quicklySugar cravingsPoor appetiteHistory of antibiotic useDifficulty digesting fatty foodsHormones + Menstrual HealthFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantPainful periodsHeavy bleedingIrregular cyclesPMSBreast tendernessHeadaches around cycleAcne breakoutsLow libidoVaginal drynessSpotting between cyclesFertility concernsHair loss/thinningFacial hair growthFeeling emotionally unstable around your cycleCycle QuestionsAverage cycle length(days)Have you ever been diagnosed with:PCOSEndometriosisFibroidsPMDDThyroid disorderOtherSkin + Histamine SymptomsFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantAcneEczemaRashesHivesItchingFlushing/rednessPuffiness/swellingSeasonal allergiesHistamine reactionsSensitivity to skincare productsMetabolism + Blood SugarFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantDifficulty losing weightRapid weight changesCravingsFeeling shaky if meals are delayedEnergy crashes after mealsIncreased thirstFrequent urinationThyroid + Temperature RegulationFor each symptom, rate the severity: 0 = Never / Not at all, 1 = Occasionally / Mild, 2 = Moderate / Frequent, 3 = Severe / ConstantCold hands/feetFeeling cold easilyExcessive sweatingHeat intoleranceDry skinHair thinningBrittle nailsHoarse voiceLifestyle + Daily HabitsNutritionHow many meals do you typically eat per day?Do you skip meals frequently?YesNoWater intake per day(in ounces)MovementCurrent exercise routineCheckboxEnergizedExhaustedAnxiousStrongInflamed/soreOtherStressHow would you rate your current stress levels?What are your biggest current stressors?Medical HistoryCurrent medications:Current supplements:Past surgeries:Known diagnoses:Family history of:Thyroid diseaseDiabetesAutoimmune diseaseHeart diseaseInfertilityMental health disordersOtherFinal Reflection QuestionsWhen do you feel your best?What symptoms interfere most with your quality of life?Do you notice any patterns with Stress? Your cycle? Food? Sleep? Exercise?Anything else you would like me to know?SubmitSave as DraftPlease do not fill in this field.
