Gut Health Questionnaire Name * First Name Last Name Email * How often do you check email? * Cell phone * (###) ### #### Age * Birthdate * MM DD YYYY Place of Birth Height * Current weight * Weight six months ago * One year ago * Would you like your weight to be different? * Yes No If so, what? * Relationship status * Where do you currently live? * Children Pets Occupation * Hours of work per week * Please list your main health concerns * Other concerns and/or goals? * At what point in your life did you feel best? * How is/was the health of your mother? How is/was the health of your father? What is your ancestry? * What blood type are you? * How is your sleep? * How many hours? * Do you wake up at night? * Yes No Sometimes Why? * Any pain, stiffness, or swelling? * Allergies or sensitivities? Please explain * Are your periods regular? How many days is your flow? How frequent? Painful or symptomatic? Please explain Reached or approaching menopause? Please explain Birth control history Do you experience yeast infections or urinary tract infections? Please explain Any serious illnesses/hospitalizations/injuries? Any surgeries in the past 10 years? * Do you take any supplements or medications? Please list * Any healers, helpers, or therapies with which you are involved? Please list * What role do sports and exercise play in your life? * What foods did you eat often as a child? * Include breakfast, lunch, dinner, snacks, liquids What is your food like these days? * Include breakfast, lunch, dinner, snacks, liquids Do you cook? * Yes No What percentage of your food is home-cooked? * Where do you get the rest from? * Do you crave sugar, coffee, cigarettes, or have any major addictions? * Are you experiencing constipation or diarrhea? * How many bowel movements per day? * When was your last bowel movement? * Are you experiencing gas or bloating? * Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? * The most important thing I should do to improve my health is: * Anything else you would like to share? Thank you, we look forward to supporting your health goals! We will be in touch shortly!