1:1 HEALTH ASSESSMENTI’m excited for you to begin on this health journey!First, I need a bit of information from you, then we’ll schedule our coaching call(s) to ensure you have all the support you need.Plan for 10-15 minutes to complete this form. All data is kept confidential. Name * First Name Last Name Email * Phone * (###) ### #### HEALTH ASSESSMENT Date of Birth * Height * Weight * Gender * Occupation * What's your primary health challenge? * Have you lost time from school or work due to this issue? If yes, how much? * What treatments have you tried? * What has been successful? * With whom do you live? * Are you under a lot of stress? * No stress Mild stress Moderate stress Much stress Extreme stress Does this health issue make you angry or sad? * Do you feel that your decision to get healthy would be supported by your friends and family? * Have you or your family recently experienced any major life changes? If yes, please comment: * Do you feel anxious in social settings? * If in a new job, list previous job. What was your reason for leaving? * MEDICAL HISTORY List past Medical and Surgical History: * List previous hospitalizations: * How often have you taken antibiotics? * How often have you have taken oral steroids? * What medications are you taking now? * List all vitamins, minerals, and other nutritional supplements that you are taking now. * YOUR DIET As a child did you eat a lot of sugar and/or candy? * What is your typical daily diet, include all meals and snacks, sports drinks, coffee, and specialty drinks. * How much of the following do you consume each week? * Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy/ chocolate, dessert Are you on a special diet? * Is there anything special about your diet that I should know? * YOUR SYMPTOMS Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? * Do you feel much WORSE when you eat certain foods? If so, what foods? * Do you feel much BETTER when you eat certain foods? If so, what foods? * Does skipping a meal greatly affect your symptoms? * Have you ever had a food that you craved or really "binged" on over a period of time? * Do you have an aversion to certain foods? If yes, what foods? * ADDITIONAL How many bowel movements (BM) do you have per day? * Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? * Do you have intestinal gas? If so, when? * If asked to eliminate certain foods for a period of time, would you be willing to, if it made you feel better? * Have you ever used recreational drugs? * Have you ever used tobacco? (If so, for how long?) * How many times per week do you drink alcohol? * Have you, to your knowledge, been exposed to toxic metals or mold in your job or at home? * Do odors affect you? If so, which ones? * Have you ever had psychotherapy or counseling? * List your hobbies and leisure activities: * Do you exercise regularly? If so, how many times a week? * What type of exercise is it? * Do your parents or siblings have (or had) any health issues? If so, please explain: * I have read and understand everything on this page. I acknowledge Susan Kostyk and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Susan Kostyk, her lab partners, her independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services. All information provided is for health education purposes only and is not intended to diagnose, treat, cure or prevent any disease. * Yes, I understand Thank you! Keep an eye on your inbox for my kickoff email with all the details about how to prepare for this health assessment. I look forward to meeting you during our coaching call. Talk soon,Sue KostykIntegrative Health Practitioner Board Certified Health Coachsue@symmetryhealthandwellness.com
