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 To Avoid Delays in Scheduling - Please Check That Your Blood Labs Have These Basic Bloodwork Panels: * Required
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
IMPORTANT: Are You Experiencing Low Energy, Fatigue, Difficulty Losing Weight, or Suspect Hormone Imbalance? * Required
I understand that if I answered YES above, I will need Blood Labs for a THYROID PANEL AND A HORMONE PANEL (Estradiol, Testosterone, Progesterone, Sex Hormone Binding Globulin) BEFORE beginning the Nourishing Roots Wellness Program
Social Information 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?
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
What factors affect your sleep?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities?
Women's Health Are your periods regular? * Required
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.
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
Additional Comments Anything else you would like to share?
I declare that the info I’ve provided is accurate & complete
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