Online Pre-Consultation Ten-Part Questionnaire

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Name

Phone

SOME BASIC QUESTIONS ABOUT YOUR METABOLISM

Any blood sugar issues

Blood Pressure

Fluid Retention

Fatigue

Cholesterol Levels

Body Weight

Do you suffer with Gout?

Do you suffer with Kidney Stones?

Do you suffer with Gall Stones?

SOME BASIC QUESTIONS ABOUT YOUR DIGESTION

Do you suffer with Indigestion

Do you suffer with Acid Reflux (Heartburn)?

Do you suffer with Constipation

Do you suffer with Bloating?

Do you suffer with Gas (wind)?

Do you suffer with Candida (or Thrush)?

Do you suffer with Irritable Bowel Syndrome?

Do you suffer with Celiac Disease?

Do you suffer with Crohn's Disease?

Do you suffer with Parasites?

Do you suffer with Stomach Ulcers?

A COUPLE OF QUESTIONS ABOUT YOUR SKIN

Do you suffer with Excema?

Do you suffer with Psoriasis?

Do you suffer with Boils?

Any other skin condition you want to describe?

Do you suffer with Acne?

JUST A COUPLE OF BASIC QUESTIONS ABOUT IMMUNITY AND INFLAMMATION

Do you suffer with any Allergies? (if so please list)

Do you suffer with Arthritis?

Do you suffer with Asthma?

Do you suffer with a sinus congestion?

Do you suffer with a lung congestion?

Do you suffer with a cough?

Any other immune disorder you can describe?

SOME QUICK QUESTIONS ABOUT YOUR STRESS LEVELS

Do you suffer with Headaches?

Do you suffer with Insomnia?

Do you suffer with Depression?

Do you suffer with Confusion or Memory loss?

Do you suffer with Palpitations?

How would you rate your stress levels?

A QUICK CHECK ON YOUR DIET HABITS

HOW OFTEN DO YOU EAT THESE ITEMS?

Alcohol

Tobacco (or Vape)

Beef & Lamb (red meat)

Burgers or Fish 'n Chips

Bread, Pastry, Cake (Baked goods)

Cheddar Cheese

Chocolate or other sweets

Standard Coffee or Tea

Energy Drinks

Other sugary drinks

Ice Cream or other desserts

Margarine

Nuts

Seeds

Potato chips

Any other junk food you want to mention?

WHAT MEDICATIONS YOU ARE TAKING?

Please list any prescription drugs you are taking

Please list any supplements or herbs you are taking

Please list any other recreational drugs you are taking (this is kept confidential)

A COUPLE OF LIFESTYLE QUESTIONS

How often do you go walking?

How often do you go running?

How often do you do garden work?

How often do you do a gym workout?

Do you have a physical job?

How often do you participate in sports?

ADD ANY EXTRA DETAILS ABOUT YOUR GOALS

Outline any other specific details of your health concern

What's your number one priority with this consultation?

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