Health Evaluation Form

Page 1

Full name

Nombre

Apellido

Gender

Female Male Non-binary Prefer not to say

Email

Phone number

Page 2

Name of the doctor or other health professionals treating you

Date of birth

Height, if known

Weight, if known

What are the main reasons you are seeking care?

Manage a chronic condition Improve energy Weight management Digestive problems Stress or sleep Preventive check-up

Lifestyle and wellbeing

How many hours do you sleep a night?

Do you have trouble falling asleep?

Do you wake often or wake easily?

Do you need to use the bathroom during the night?

Do you snore or have breathing problems while asleep?

Do you have any known allergies?

List any allergies you know of

List the medication you take (for example anticoagulants, contraceptives, laxatives)

List the supplements you currently take

Do you have a main complaint? Please describe it.

Are any of these conditions present in your family history? Tick all that apply.

Any extra information you want to share

Page 3

Do you exercise?

Yes, regularly Occasionally No

List the types of exercise you do regularly

Do you smoke?

How many cigarettes per week?

Do you use recreational drugs?

List any food allergies or intolerances you know of

How many glasses of water do you drink a day?

Do you drink alcohol?

Yes, regularly Occasionally No

How many alcoholic drinks per week?

Page 4

Exercise frequency (days per week)

Are you vegetarian or vegan?

Are you over 50 years old?

Are you planning a baby in the next three to six months?

Are you pregnant or breastfeeding?

Page 5

Do you diet often?

Are you unhappy with your weight?

Page 6

Is there a family history of diabetes, cardiovascular disease, cancer or another serious illness?

Would you like a copy of your questionnaire emailed to you?

Preferred email address