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Holistic Health Assessment Form

Birthday
Do you...
Smoke tobacco
Use illicit substances
Drink alcohol
None of these
Is your blood pressure...
Is your cholesterol...
Do you eat when you don't feel physically hungry?
Yes
No
Do you have cravings for any particular foods?
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...
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
Do you spend much time outdoors in nature?
Yes
No
Not as much as I'd like
Do you experience high amounts of stress in your day to day life?
Yes
No
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
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...
Adrenals. Select all that apply...
Pancreas. Select all that apply...
Gastrointestinal tract. Select all that apply...
Liver/Gallbladder/Blood. Select all that apply...
Heart & Circulation. Select all that apply...
Skin complaints. Select all that apply...
Lymphatic System. Select all that apply...
Kidneys/Bladder. Select all that apply...
Lungs. Select all that apply...
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