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Health History

Do you have any known allergies? If yes, please specify:

Do you have any chronic medical conditions? If yes, please specify:

Are you taking any medications or supplements? If yes, please specify:

Nutritional History

Have you ever consulted a nutritionist or dietician before?

Do you have a history of dieting, eating disorder, or disordered eating?

if yes, please specify:

Do you have any current dietary restrictions?

If "other", please specify:

How would you describe your current eating habits?

Please describe your current eating habits in your own words:

Holistic Components

On average, how many hours of sleep do you get per night?

Is there anything affecting your sleep patterns? Select all that apply:

If "other", please specify:

Please rate your stress levels on a scale of 1-10, 10 being the highest.

Symptom Assessment

Do you experience any of the following? Please select all that apply:

Female Health

Please select all that apply:

Do you experience any of the following? Please select all that apply: