Let’s learn about your current health. Please take some time to fill in the Questionnaire below. Name First Last Do you have any medical conditions? Do you take any regular medication or supplements? Please list: Do you have any significant family history?Cancer, cardiovascular disease, mental health, Alzheimer's or dementia etc. Do you follow a particular diet? Yes No If yes, which one?E.g. Vegan, Keto, Paleo Please describe your typical food intakeBreakfast, lunch, dinner and snacks. How often do you eat takeaways or eat out? Daily 4-5 times a week 2-3 times a week Once a week or less Do you experience cravings for any particular food or drink?E.g. Salt, sugar or alcohol Yes No If yes, what do you craving/s do you experience? Do you have any food allergies or feel like you react to certain foods? Yes No If yes, which food/s? And is it an allergy or reaction? Do you eat when your not hungry?E.g. Eat when you feel emotional or bored Yes No If yes, please provide details How often do you eat "on-the-go" or in front of the TV, computer or on your phone? Daily 4-5 times a week 2-3 times a week Once a week or less How much water do you drink per day?Excluding caffeinated beverages Do you drink coffee, caffeinated tea or energy drinks? Yes No If yes, how many cups per day? Do you drink alcohol? Yes No If yes, how many standard drinks per week? Do you smoke cigarettes? Yes No Ex-smoker If yes, how many per week? How often do you feel low in energy or fatigued? 1 - Never 2 3 4 5 - Daily How often do you experience a "3pm slump" or "crash in energy"? 1 - Never 2 3 4 5 - Daily How often do you exercise? Daily 4-5 times a week 2-3 times a week Once a week or less What type/s of exercise do you do?Please list How often do you experience muscle soreness or aches in your body following exercise? 1 - Never 2 3 4 5 - Every time I exercise What time do you go to sleep? What time do you wake up? On average, how many hours do you sleep for each night? Do you often feel "wired" or experience increased energy in the evening? 1 - Never 2 3 4 5 - Daily How often do you wake up unrefreshed? 1 - Never 2 3 4 5 - Daily Do you experience high amounts of stress in your day to day life? Yes No If yes, what is the main source/s of stress?E.g. Work, financial, relationship 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 How often do you connect with family and friends? 1 - Rarely 2 3 4 5 - Daily How often do you spending time relaxing? 1 - Never 2 3 4 5 - Daily Do you have any stress reduction tools that you use on a regular basis?E.g. Meditation, deep breathing, music, journaling, spiritual or religious practices Is your weight of concern to you? Yes No If yes, do you want to lose, maintain or put on weight? How often do your bowels open? Do you regularly experience constipation or diarrhoea? Yes No If yes, please provide details Do you experience reflux, bloating or gas? Yes No Do you suffer from headaches or migraines? Yes No Do you suffer from recurring infections or frequent illness? Yes No If yes, please provide details Do you have any skin concerns?E.g. Acne, eczema, psoriasis Yes No If yes, please provide details Do you use organic, non-toxic skin care and make-up? Yes No Do you use eco-friendly, low-toxin home cleaning products? Yes No For WomenHave you ever been on the oral contraceptive pill or other hormonal contraception? Yes - current Yes - past No If yes, what contraception? And how many years have you used it? Are you currently pregnant or breastfeeding? Yes No If yes, pregnant or breastfeeding? Do you track your menstrual cycle? Yes No If yes, what is the length of your menstrual cycle on average?i.e. 28-35 days How many days is your period (bleed days) on average? Do you experience PMS in the lead up to your period?E.g. Bloating, cravings, irritability, breast tenderness Yes, every cycle Only some cycles but I don't know why Only some cycle but I know why No, never What sanitary items do you use?E.g. Pads, tampons, moon cup, period underwear And finally..What is the most important thing you want to achieve while working with me?Your number one goal. Why is this goal important to you? Do you anticipate any obstacles on the way to achieving this goal?Is there anything that typically holds you back from meeting your goals? Is there anything else relevant to your health and wellbeing that you would like me to know?