Please list Skype name/ID, FaceTime phone number, if applicable.
Date of birth
Weight one year ago
Were you born full term?
Were you born vaginally?
Were you breastfed, and if yes, for how long?
Have you lived or traveled outside of the United States? If so, when and where?
Have you or your family recently experienced any major life changes? If yes, please explain.
Have you experienced any major losses in life? If yes, please explain.
What other health practitioners are you currently seeing? Please list name, specialty, and phone number (if available).
How many functional and/or integrative practitioners have you worked with previously? If you aren't sure what this means, please note none.
List out the labs and testing you've had done in the past 2 years by doctors and other practitioners. This includes standard blood work, urine testing, stool testing, metabolic testing, food sensitivity testing, genetic testing, etc.
Please list the date and description of any surgical procedures you've had (appendectomy, tonsillectomy, etc.).
Have you used antibiotics? If yes, please describe when and how often.
Please list any over the counter medications you've taken, and how often (ibuprofen, Tylenol, antacids, etc.).
Please list any prescription medications you are taking.
Please list any vitamins, minerals, herbs and nutritional supplements you are taking, their dose and how often you take them.
What skin care products, cosmetics, perfume, cologne, shampoo, conditioner, etc. do you use? Please be as specific as possible.
What household cleaners, soaps, detergents, etc. do you use? Please be as detailed as possible.
Do you experience any of the following symptoms? Check all that apply.
Watery or itchy eyes
Bags or dark circles under eyes
Blurred or tunnel vision
Earaches, ear infections
Ringing in ears
Excessive mucus formation
Sore throat, hoarseness, loss of voice
Gagging, frequent need to clear throat
Swollen or discolored tongue, gums, lips
Cracks, sores at sides of mouth
Flushing, hot flashes
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Shortness of breath
Pains or aches in joints
Pain or aches in muscles
Feelings of weakness, tiredness, fatigue
Stiffness or limitation of movement
Cravings for certain foods
Confusion, poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering or stammering
Frequent or urgent urination
Genital itch or discharge
Do you have any health concerns or issues that you've either received an official diagnosis for or believe that you have?
What are your main health concerns? Please describe in detail including the severity of symptoms on a scale of 1-10 with 1 being not severe and 10 being very severe.
Have any family members experienced health problems similar to yours? If yes, please explain.
When did you first experience these concerns?
What was your diet like when you started experiencing your health problems? Please describe.
What else was happening in your life when your health problems began? Please explain.
What changes have you already tried to help manage your health problems, and did they work or not? Please describe.
Are there foods you avoid because of the way they make you feel? If yes, please list the foods, and describe how they make you feel.
Do you experience symptoms immediately after eating, like bloating, gas, belching, hives, or breathing problems (or other)? If yes, please explain.
Do you experience diarrhea or constipation? If yes, please describe and explain.
Do you experience symptoms such as fatigue, muscle aches, sinus congestion, etc.? If yes, please explain.
Do you experience any food cravings? If yes, please explain.
Do you have any food allergies or food sensitivities? If yes, please explain.
What is a typical day's diet for you currently? Please list a typical breakfast, lunch and dinner, as well as snacks and all beverages consumed in a day.
How much water (plain water) do you drink each day?
Have you had periods of eating junk food, binge eating or dieting? Please list any known diet that you have been on for a significant amount of time.
Are you currently on a special diet? Please explain, the diet, and why you follow it.
How many meals per week do you cook and eat at home?
How many meals per week do you eat out, or order in?
What do you think needs to change regarding your diet?
What has been stopping you from making this change on your own?
Is there anything else about your diet that you'd like to share? If yes, please explain.
Exercise/recreation, please explain
Do you drink alcohol? If so, please note number of drinks per week consumed.
Have you ever had problems with addiction?
Do odors affect you? If yes, please explain.
Do you smoke, are you exposed to smoke, or are you exposed to second hand smoke? If yes, please explain.
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)? If yes, please explain.
Have you been exposed to mold, cleaning chemicals/products, herbicides/pesticides, carpets/rugs? Please describe.
How is your oral health, and when did you last visit the dentist?
Do you have mercury amalgam fillings?
What causes you stress, and how do you handle it? Please describe.
How many hours per night do you sleep?
Do you wake feeling rested?
Do you have a hard time falling asleep?
Do you have a hard time staying asleep?
What types of activities do you participate in socially with others?
Women, if you checked other in the question above, please describe.
Do you have any concerns or issues with your sexual functioning that you’d like to share (pain with intercourse, dryness, libido issues, erectile dysfunction)?
How are your moods in general? Do you experience more anxiety, depression or anger than you would like?
Are you satisfied with your energy levels? Please describe.
At what point in your life did you feel best? Why?
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? If yes, who will be the most supportive? If no, please explain.
What 3 specific changes would you like to gain from working with Jennifer?
On a scale of 1 - 5, with 5 being 100% committed, how committed are you to feeling better within 90 days? If you didn't check a 5 on the scale, what's holding you back from being fully committed? Please explain.
What is your vision of your life for the future? Where do you see yourself in 5-10 years from now, and what is your life like then?
Please describe any other information you think would be useful in helping to address your health concern(s).
What are your health goals and aspirations?
Though it may seem odd, please consider why you might want to achieve these goals and aspirations for yourself. Please explain.
How did you hear about us, and who may we thank for the referral?