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Email
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Phone Number
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Age
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Date of Birth
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Place of Birth
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Address: Number & Street
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Address: City, State, Zip
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Relationship status
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Single
In a committed relationship
Married
Separated
Divorced
Age and gender of partner
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Age and gender of children
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What kind of pets do you have?
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Health Information
Height
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Weight
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Weight 6 mos ago
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Weight 1 yr ago
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Ideal Weight
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At what point in your life did you feel best?
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Any serious illnesses or injuries? When?
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Describe any current medical or alternative treatments.
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List any medications or supplements you're taking.
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How was the health of your mother?
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How was the health of your father?
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How is your sleep?
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I get plenty.
I get barely enough.
I don't get enough.
How many hours do you sleep on average?
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Describe any pain, stiffness or swelling.
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Describe any constipation, diarrhea, bloating or gas.
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How is your mood? Please describe.
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How is your anxiety? Please describe.
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Describe any allergies or sensitivities.
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Are your periods regular?
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Most of the time
Some of the time
Not usually
No periods
How many days is your flow?
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Have you reached or are you approaching menopause?
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Reached, no periods
Reached, still in transition
Approaching, early stages
Not approaching yet
Painful or symptomatic? Please explain.
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Birth control medication history
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Do you experience UTIs or yeast infections?
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Yes, often
Yes, sometimes
No, rarely
What are your main physical and/or mental health concerns at this time?
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Food Information
What foods did you eat often growing up?
Breakfast (past)
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Lunch (past)
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Dinner (past)
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Snacks (past)
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Late Night Snacking? (past)
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Often
Occasionally
Rarely
Liquids (past)
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What foods are you eating now?
Breakfast (now)
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Lunch (now)
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Dinner (now)
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Snacks (now)
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Late Night Snacking? (now)
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Often
Occasionally
Rarely
Liquids (now)
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Other Information
What is your occupation?
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Do you like it?
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Yes, mostly
Yes and no
Not very much
N/A
Hrs / wk
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What kind of exercise are you doing?
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How frequently?
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How are things going in your spiritual practice?
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How are things going in your primary relationship?
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How are your relationships with family, friends, coworkers, clients?
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Will your family & friends be supportive of lifestyle changes you'd like to make?
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Yes, mostly
Somewhat
Not really
Describe any food, drug, or activity addictions you have.
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Describe what you want to improve most about your health.
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Home
About
Why the Phoenix?
Testimonials
My Office
Services & Fees
>
Scholarship Program
Counseling, Coaching & Consulting
Mental Health Counseling
>
Holistic Psychotherapy
Trauma Therapy / EMDR
Clinical Hypnotherapy
HeartMath / Biofeedback
Tapping / TFT / EFT
Transformation Coaching
>
My Approach
Traditional Naturopathy
Plant Based Lifestyle Coaching
EMDR Consulting
Distance Sessions
Other Services
Yoga & Yoga Therapy
>
IYT / Kripalu Yoga
Taiji & Qigong
Meditation
Reiki
Public Speaking & Seminars
Resources
Downloads
>
My Books
FREE Downloads!
Natural Living & Healing
>
CBD Therapy
Grow Your Own Food
Healing Centers
Off the Grid
Ecovillages
Rover Scouting 4 Adults
Connect
Blogs
>
PhoenixWay Vlog/Blog
Psychology Today Blogs
Good Therapy Blog
IIN Health Blog
Intake Forms
Wellness Surveys
>
Women's Wellness Survey
Men's Wellness Survey
Wellness Survey Update
Wellness Partnerships