Holistic Assessment Please ensure you have at least 30 minutes to do this confidential questionnaire. Step 1 of 70%Personal InformationFirst Name*Last Name*AgeSexFemaleMaleHeightWeightEmail* Phone number*Let's assess your lifestyle!What is your purpose for reaching out to me?What are your main health concerns/complaints?Please list in priority.Mental HealthHave you experienced any major trauma in the past 5 years?YesNoWhat major trauma have you experienced?What level of stress do you feel you are experiencing at this time?Not stressed at allMildly stressed- manageableStressed- I need guidance to make some life changesVery stressed! I need help like, YESTERDAYWhat are the major causes or factors of your stress?(rate all that apply on a scale of 1 (low) to 10 (high)Financial12345678910Career12345678910Personal12345678910Relationship12345678910Health12345678910Family12345678910Spiritual12345678910Unfulfilled Expectations12345678910OtherYesNoOther (Please elaborate)How does stress affect you?Do you use any coping mechanisms?Physical HealthWhat do you do for exercise?(Indicate type, frequency, time of day and duration) If none, just leave blank.How would you describe your daily energy levels? High energy in the morning- I am most productive first thing in the morning No energy in the morning- struggle getting out of bed High energy in the late morning Low energy in the late morning- I can’t wait until my lunchtime nap High energy in the afternoon- I get a second wind! Struggle to stay awake in the afternoon- I find myself even reaching for food to help High energy in the evenings. I feel my best at this time. Low energy by evening. Struggle to participate in evening events because I am so tired. Energy is fine and consistent all day. Wake up fine, fall asleep fine with restful sleep. OtherOther Daily Energy - Please describeHow many hours on average do you sleep daily? (Include naps)8-10 hoursLess than 8Less than 5What time do you go to sleep?Between 8-9 pmBetween 9-10 pmBetween 10-12 amLate into the nightIt variesWhat time do you wake up?Between 5-6 am or earlierBetween 6-8 amBetween 8-10 amLate into the morning or afternoonIt variesDo you have trouble falling asleep?YesNoDo you have trouble staying asleep?YesNoDo you awaken feeling rested?YesNoWhat is your relationship like with your weight?Yes I feel I would be healthier if I lost weightYes I feel I would be healthier if I gained weightMy weight fluctuates and I’ve been a victim of every single fad diet.No, my weight does not concern me at all.List any personal goals you have for your physical health. (Lose or gain weight, get stronger, increase flexibility, breathe better, etc.)Work/Student LifeWhat is your occupation/what do you spend most of your time on in a day?Do you enjoy your work?YesNoMost of the timeSometimesHow many hours each day do you work?0-5 hours5-8 hours8-10 hours12+ hoursIt variesWhat are your driving passions, hobbies and interests?Describe your career spiritEntrepreneurial – I work for myselfCorporate - I work for a large organizationPublic Service (Teachers, police, firefighters, healthcare etc.)Customer Service or HospitalityReligious or Volunteer workStay At Home ParentRetiredOtherOther Career SpiritSpiritual HealthDo you actively participate in any spiritual discipline(church, religious group, Meditation, etc.)YesNoI’m struggling with what fits with my life pathMedical HistoryAre you currently taking any medication?YesNoList all medications and the reason(s) for eachHave you taken antibiotics over the past five years?YesNoHow many times, and for what purpose?Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosages:Do you have any food/chemical allergies or sensitivities?YesNoDo you smoke?YesNoYes and trying to quit. Help me!!Please list and describe how smoking affects you and how long you have experienced these affects.Have you ever been diagnosed with an illness or been hospitalized?YesNoPlease explain the details of your illness and/or hospitalization.Have you had surgery to remove your gall bladder?YesNoHow often do you have a bowel movement?Once per day1-3 times per day3-5 times per weekOnce per week or lessIt variesDo you strain to have a bowel movement?YesNoOccasionallyIs it related to particular food or circumstances?Do you have loose bowel movements?YesNoOccasionallyIs it related to particular food or circumstances?Is there undigested food in your stool?YesNoOccasionallyIs it related to particular food or circumstances?Do you use recreational drugs?YesNoOccasionallyHow often do you use recreational drugs, and what type?Have you experienced fungal infections?(e.g. jock itch, athlete’s foot, thrush or vaginal yeast infections)YesNoIf yes, please describeHave you had kidney or gall stones?YesNoIf yes, please describeReproductive HealthHave you experienced a decline in sexual interest?YesNoFemalesAre you or could you be pregnant?YesNoHave you ever been pregnant?YesNoHow many pregnancies have you had?Do you take birth control pills or have an IUD?YesNoIf yes, please describe your method of birth control and if there are any current discomfort or negative changes associate with itHave you noticed any changes in menses, for example the frequency, duration, flow, clotting, or other changes?YesNoIf so, please specifyDo you suffer from PMS symptoms?YesNoIf yes, please describe your experience over the last three cycles that you can remember.Are you pre-menopausal?YesNoAre you post-menopausal?YesNoAre you experiencing any menopausal symptoms?YesNoIf yes, please specifyMalesHave you experienced any prostate problems?(e.g. frequent urination, discomfort during urination)?YesNoIf yes, please describeDietary HabitsHow many times do you eat during a day?Three times per day and a few snacksOne big meal per dayOne big meal per day with lots of coffee, sodas or alcoholic beveragesEat multiple times per daySometimes I forget to eat. But live off coffee, sodas or alcoholic beveragesHow do you eat your meals? With family Home alone On the run Eat out at restaurants Grab fast foodDo you feel there are restrictions to your diet due to preferences of others such as family, roommates, etc.?YesNoDo you eat breakfast?YesNoIf yes, please describe a typical breakfastProvide examples of your typical lunch.Provide examples of your typical dinner.Provide examples of your typical snacks.How often do you use margarine?Rarely or neverRegularlyOftenHow often do you eat candy/chocolates?Rarely or neverRegularlyOftenHow often do you eat fried or fast foods?Rarely or neverRegularlyOftenHow often do you eat lunch meats?Rarely or neverRegularlyOftenHow often do you use artificial sweeteners (Nutra Sweet, aspartame, Splenda)Rarely or neverRegularlyOftenHow often do you eat Refined foods (pastries, white bread/pasta/rice, etc.)?Rarely or neverRegularlyOftenPlease indicate how many cups of water you drink per day:NoneLess than 22-5All day long!Please indicate how many cups of coffee you drink per day:NoneLess than 22-5All day long!Please indicate how many cups of soda you drink per day:NoneLess than 22-5All day long!Please indicate how many cups of red wine you drink per week:NoneLess than 22-5All day long!Please indicate how many cups of white wine you drink per week:NoneLess than 22-5All day long!Please indicate how many cups of beer you drink per week:NoneLess than 22-5All day long!Please indicate how many cups of hard liquor you drink per week:NoneLess than 22-5All day long!Please indicate how many cups of cow’s milk (1%, 2% or whole) you drink per day:NoneLess than 22-5All day long!Please indicate how many cups of energy drinks you drink per day:NoneLess than 22-5All day long!Which best describes you?Meat EaterVegetarianVeganWhole FoodsRaw FoodieWhat are your favourite foods, and how often do you eat them?Which food(s) do you crave, and how often do you eat them?Do you experience any symptoms if meals are missed? Explain:Are there any other habits, symptoms or other details you'd like to list?Δ
