General symptoms and sensitivities:

Please fill in a number 0-5

0: not present

1: rarely present

2: sometimes present

3: regularly present

4: almost always present

5: always present

Bloating

Brain fog

Food sensitivities

Sinus issues

Rashes

Eczema

Stomach-Ache

Gluten sensitivity

Hair loss

Acid reflux

Burning sensation after eating

Difficulty digesting meat

Foul smelling stools

Excessive gas

Stomach pain

Diarrhea

Constipation

Teeth grinding

Muscle aches

Insomnia

Waking more than one time to pee during the night

Intrusive thoughts

Nightmares

Constant hunger

Red eyes

Itchy skin

Anxiety

Excessive thirst

Cough

Shortness of breath

Chest pain

Always hot

Always cold

Blurry vision

Mood swings

Frequent sore throats

Prolonged cold symptoms

Difficulty digesting high fat foods

Swollen lymph nodes

Body odor

Salt craving

Sugar cravings

Tired in the morning

Excessive stress

Frequent headaches or migraines

Irritability or nervousness

Hand tremors or hand shakiness

Low libido

Dark urine

Yellowish eyes

Erectile dysfunction (Men)

Morning erections (Men)

Irregular periods (Women)

Painful periods (Women)

Missed periods (Women)

Consumption:

Please fill in a number 0-5 for consumption

0-Never

1-rarely

2- sometimes

3-regularly

4-often

5- always

Vaping/ E-cigs

Cannabis use

Caffeine

Alcohol

Other recreational drugs (please specify)

Over-the-counter pain medication like ibuprofen or Advil

Tums/ ant-acids

Eating out at restaurants

Drive-through fast food

Sun exposure

Conventional sunscreen use

Fluoridated toothpaste

Nonstick pan usage

Plastic Tupperware/utensils usage

Sleep:

On average, how many hours of sleep do you get per night?

About how long does it take you to fall asleep?

How many hours before bed is your last meal?

Is there a Wi-Fi router in your bedroom?

Does your phone charge on your nightstand?

Is your bedroom completely dark at night?

About how many times do you wake up during the night to go to the bathroom?

Nutrition Screening:

How long after waking do you eat your first meal?

Do you drink coffee before your first meal?

Do you eat any prepackaged or microwaved foods?

Please describe a typical breakfast:

Please describe a typical lunch:

Please describe a typical dinner:

Please describe any snacks:

What beverages do you consume regularly?

Are there any particular foods that illicit any negative digestive responses?

Please list any current prescribed medications you are taking as well as frequency and dose:

Please list any supplements you are currently taking as well as frequency and dose:

Exercise:

Please briefly describe any current training or exercise regimen:

Details:

Full Name *

Phone *

Email *