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Nourishing Roots

Nutrition & Wellness Coaching

Helping You Achieve Vitality

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Request My In-Depth Health Assessment

Our In-Depth Health Assessment
Begins with Completing and Submitting THREE things...

Health History Form
Symptom Survey
Most Recent Bloodwork

Female Health History

All of your information will remain confidential between you and the Nourishing Roots Team. Answers are required on most questions. Respond N/A if something does not apply to you.

Personal Information

First Name

Last Name

Email

Mobile Phone

Other Phone

Address

Date of Birth * required

Ideal Weight

Height

Current Weight

Blood Pressure

IMPORTANT: Have You Had Blood Labs Done w/in last 12 mos? (IF LONGER THAN 12 MONTHS, YOU WILL NEED TO HAVE MORE RECENT BLOODWORK DONE)

To Avoid Delays in Scheduling - Please Check That Your Blood Labs Have These Basic Bloodwork Panels: * Required

Standard Lipid Panel

Metabolic Panel

Vitamin D

Complete Blood Count with Differential

If my Blood Labs do NOT have the above information, I understand I will need to have another blood draw to obtain this information. * Required

YES

Yes (just making sure you understand)

IMPORTANT: Are You Experiencing Low Energy, Fatigue, Difficulty Losing Weight, or Suspect Hormone Imbalance? * Required

Yes

No

I understand that if I answered YES above, I will need Blood Labs for a FULL THYROID PANEL AND A HORMONE PANEL (Estradiol, Testosterone, Progesterone, Sex Hormone Binding Globulin) BEFORE having my In-Depth Health Assessment.

Social Information

How did you hear about Nourishing Roots?

Relationship Status

Occupation

Children

Hours of Work Per Week

Pets?

Day to day, what emotions do you most commonly feel and why?

Health Information

Please list your main health goals:

Other health concerns and goals?

At what point in your life did you feel your best?

If you could wave a magic wand and change two things, what would they be?

Any serious illnesses/diagnoses/surgeries/injuries and past hospitalizations?

How is/was the health of your mother?

How is/was the health of your father?

How is your sleep? * Required

Good

Fair

Bad

Average hours per night?

Do you wake up at night?

What factors affect your sleep?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities?

Women's Health

Are your periods regular? * Required

Yes

No

N/A

How many days is your flow?

Painful or symptomatic?

Reached or approaching menopause?

Birth control history:

Do you experience yeast infections or urinary tract infections?

Medical Information

Do you take any supplements or medications?

Any healers, helpers, or therapists with which you are CURRENTLY involved?

Any healers, helpers, or therapists you have worked with in the PAST?

What role do sports and exercise play in your life?

Food Information

List the food you ate for one day in the past week that represents your typical diet.

What % of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

Do you have any food allergies or sensitivities?

The most important thing I should do to improve my health is:

Complete Symptom Survey Here

Click the Button below to complete the Symptom Survey

Complete Symptom Survey

I understand that I must complete the Symptom Survey in order to schedule my In-Depth Health Assessment.

Upload Blood Labs Here

Upload File

Upload supported file (Max 15MB)

Multiple File Upload

I declare that the info I’ve provided is accurate & complete

Thank You

Male Health History

All of your information will remain confidential between you and the Nourishing Roots Team. Answers are required on most questions. Respond N/A if something does not apply to you.

Personal Information

First Name

Last Name

Email

Mobile Phone

Other Phone

Address

Date of Birth * required

Ideal Weight

Height

Current Weight

Blood Pressure

IMPORTANT: Have You Had Blood Labs Done w/in last 12 mos? (IF LONGER THAN 12 MONTHS, YOU WILL NEED TO HAVE MORE RECENT BLOODWORK DONE)

To Avoid Delays in Scheduling - Please Check That Your Blood Labs Have These Basic Bloodwork Panels: * Required

Standard Lipid Panel

Metabolic Panel

Vitamin D

Complete Blood Count with Differential

If my Blood Labs do NOT have the above information, I understand I will need to have another blood draw to obtain this information. * Required

YES

Yes (just making sure you understand)

IMPORTANT: Are You Experiencing Low Energy, Fatigue, Difficulty Losing Weight, or Suspect Hormone Imbalance? * Required

Yes

No

Social Information

How did you hear about Nourishing Roots?

Relationship Status

Occupation

Children

Hours of Work Per Week

Pets?

Day to day, what emotions do you most commonly feel and why?

Health Information

Please list your main health goals:

Other health concerns and goals?

At what point in your life did you feel your best?

If you could wave a magic wand and change two things, what would they be?

Any serious illnesses/diagnoses/surgeries/injuries and past hospitalizations?

How is/was the health of your mother?

How is/was the health of your father?

How is your sleep? * Required

Good

Fair

Bad

Average hours per night?

Do you wake up at night?

What factors affect your sleep?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities?

Medical Information

Do you take any supplements or medications?

Any healers, helpers, or therapists with which you are CURRENTLY involved?

Any healers, helpers, or therapists you have worked with in the PAST?

What role do sports and exercise play in your life?

Food Information

List the food you ate for one day in the past week that represents your typical diet.

What % of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

Do you have any food allergies or sensitivities?

The most important thing I should do to improve my health is:

Complete Symptom Survey Here

Click the button below to complete the Symptom Survey

Complete Symptom Survey

I understand that I must complete the Symptom Survey in order to schedule my In-Depth Health Assessment

Upload Blood Labs Here

Upload File

Upload supported file (Max 15MB)

Multiple File Upload

I declare that the info I’ve provided is accurate & complete

Thank You

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Request Your In-Depth Health Assessment

Nourishing Roots, LLC

Located in the beautiful Atrium building

2515 Foresight Circle, Ste 260

Grand Junction, CO 81505

(970) 812-3201

Email: info@nourishingrootsgj.com

© 2023 ReMerJuLes

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