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Holistic Health Assessment Form
First name
Last name
Birthday
Day
Month
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?
Submit
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