Holistic Health Assessment | A Nourishing Notion

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Holistic Health Assessment Form

First name

Last name

Birthday

Day

Month

Year

What is the main reason(s) for seeking my assistance? What are your goals, dreams, desires? Your "why"?

What holds you back from achieving your goals? Have you identified your limiting beliefs?

Briefly describe your typical day of eating/drinking...

Do you have any allergies or intolerances (including food)?

When did you last see your GP?

Are you on any regular medication or taking herbs/supplements? Please list:

Do you have any diagnosed medical conditions? Have you had surgery (please provide details)

Do you have any significant family history?

Did you get the Covid vaccination? If so, how many and approx. when?

Do you...

Smoke tobacco

Use illicit substances

Drink alcohol

None of these

Caffeine: do you drink coffee, black tea or energy drinks? How many? How often?

How would you describe your energy levels?

Is your blood pressure...

High

Low

Normal

Is your cholesterol...

High

Normal

Do you eat when you don't feel physically hungry?

Yes

No

Do you have cravings for any particular foods?

Salt

Sugar

Alcohol

Other

Do you snack after dinner or eat late at night?

Yes

No

Is your weight of concern to you?

Yes

No

Do you use conventional household cleaners and personal care products with synthetic fragrances (including home fragrances and scented candles etc)?

Yes

No

Do you experience low libido? *

Yes

No

Sometimes

Do you have any concerns regarding sexual function?

Yes

No

Have you ever been on the oral contraceptive pill or other hormonal contraception?

Yes

No

Select all that apply to you...

Fibroids, now or in past

Ovarian cysts, now or in past

Endometriosis, now or in past

Atypical cervical cells, now or in past

If you have been through menopause, at what age & did you experience severe symptoms?

Do you know the length of your cycle? If yes, how many days typically? Is it regular?

Do you experience PMS (eg, bloating, cravings, irritability, breast tenderness) in the lead up to your period? Please provide details:

How many days does your period last for? Is it heavy? Cramps?

What do you use when you're menstruating?

A Menstrual Cup

Pads

Tampons

Period Underwear

Other

Have you ever been pregnant?

Yes

No

Have you ever given birth (either vaginally or c-section)?

Yes, vaginally

Yes, c-section

Yes, both

No

Are you experiencing fertility concerns?

Yes

No

Do you have any pelvic floor concerns?

Yes

No

Have you ever taken antibiotics? If so, how many times and when was the last time?

What do you do for exercise/movement?

Do you spend much time outdoors in nature?

Yes

No

Not as much as I'd like

How much water (excluding caffeinated beverages) do you drink per day?

What is your water quality like? Is it chlorinated of fluoridated? Rural? Filtered?

Do you have a history of abuse, neglect, anxiety or depression, or other enduring mental illness?

Do you feel socially connected in your life?

If you are in a relationship; is it loving, kind, respectful and fulfilling?

Do you experience high amounts of stress in your day to day life?

Yes

No

If yes, what are the main sources of stress?

Do you prioritise time for yourself?

Yes

No

Do you consistently overcommit to things/people/activities in your life?

Yes

No

Do you have difficulty setting boundaries with others?

Yes

No

Do you have any stress reduction tools that you use on a regular basis (eg. meditation, tai chi, Qi gong, yoga, breathing, music, journaling, spiritual or religious practices)?

Yes

No

What time do you go to sleep?

What time do you wake up?

Do you wake feeling refreshed?

Yes

No

Sometimes

Do you have EMF emitting devices such as WIFI, cell phones, TV or Bluetooth in the bedroom at night?

Yes

No

Sometimes

Do you have any pre-bedtime rituals?

Yes

No

Sometimes

Thyroid/parathyroid. Select all that apply...

Spider veins or varicose veins

Haemorrhoids

Brittle, weak or ridged nails

Cold hands or feet

Hair loss

Muscle cramps

Headaches or migraines

Feel the cold

Hernia

Prolapse

Aneurysm

Irregular heart beat or flutters/palpitations

Low bone density

Disc herniation

Sweat profusely

Don't sweat at all

Adrenals. Select all that apply...

Anxiety/panic attacks

Excessive shyness or feeling inferior

Tremors

Restless legs

Tinnitus

Shortness of breath or "air hunger"

Heart arrhythmias

Tire easily

Lower back weakness

Sciatica now or in past

Get up to pee in the night

Get a "second wind" of energy in the evenings

Pancreas. Select all that apply...

Gas after eating

Food sits in your stomach

Acid reflux

Undigested food in stools

Low blood sugar

Difficulty putting on weight

Food passes right through you

Moles on body

Gastrointestinal tract. Select all that apply...

Tongue coated, especially in morning

Diarrhoea

Constipation

Stomach ulcers, now or in past

Excessive gas problems

Smelly gas and stools

Stomach cramps

Bloating

How often do you pass a bowel motion?

Liver/Gallbladder/Blood. Select all that apply...

Problem digesting fats

Fats and dairy food cause bloating and/or pain

Stools white or very light brown

Pain in middle of back especially after eating

Pain behind right lower rib area

Liver spots on skin (not freckles)

Skin pigmentation changes

Anaemia

Heart & Circulation. Select all that apply...

Grey hair

Memory issues

Tired of crampy legs after walking

Bruise easily

Angina or chest pains

Pressure on chest

Skin complaints. Select all that apply...

Dry skin

Itchy skin

Excessively oily skin

Psoriasis

Eczema/dermatitis

Skin blemishes

Acne

Dandruff

Lymphatic System. Select all that apply...

Sinus issues

Sore throats

Swollen lymph nodes

Any type of tumour (benign or malignant)

Low platelets

Poor immune system function - frequent illness

Boils, pimples, skin infections

Gout

Blurred vision

Sleep/mucus in eyes on waking

Snore

"Puffiness"/ fluid rentention

Kidneys/Bladder. Select all that apply...

History of urinary tract infection

Burning when you pee

Problems holding bladder

History of kidney stones

Bags under your eyes especially in morning

Cramping or pain either side of mid to lower back

Lungs. Select all that apply...

Get, have or have had bronchitis

Get, have or have had pneumonia

Get, have or have had asthma

Get, have or have had COPD

Pain when you breathe

Pain on deep inhalation

Worked around toxic chemicals

Cough a lot

Mucus-y, have to spit/clear phlegm often

Is there anything else of relevance to your holistic wellbeing that you would like me to know?

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The information provided on this website should NOT be used for the purposes of diagnosing, treating, preventing, or curing any disease, as it is not intended to be a substitute for direct, personalised advice from a health professional.

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