Health History
Please complete before your first session. All responses are confidential.
Section 1 — Your Health
Do you have any current health conditions or diagnoses?
Have you had COVID-19?
Are you currently seeing a physician or other healthcare provider?
How would you describe your current relationship with your healthcare providers? Do you feel supported? Are there gaps or concerns you'd like to address?
Are you currently taking any medications?
Are you currently taking any supplements or vitamins?
How are these health concerns impacting your daily life?
Section 2 — Hormonal Health
Where are you in your hormonal journey?
Are you currently on hormone therapy?
Are there any hormonal or reproductive health concerns you'd like me to know about?
How are these hormonal changes or concerns impacting your daily life?
Section 3 — Lifestyle
How would you describe your overall sleep quality?
How would you describe your overall energy level?
How would you describe your overall mood?
How would you describe your overall stress level?
How would you describe your eating habits?
How would you describe your physical activity?
How would you describe your relationships and social support right now?
How would you describe your current work situation?
Is there anything else about your lifestyle you'd like me to know?
How are these lifestyle factors impacting your daily life?
Section 4 — Your Goals
What are your main wellness goals right now?
What has gotten in the way of reaching these goals in the past?
What are you hoping to get out of our work together?
Your responses are confidential and will be reviewed before your first session.
Something went wrong. Please try again or reach out directly.
Thank you
Your health history has been submitted.
I will review your responses before your first session.
I look forward to meeting you.