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Part 2

First and Last Name (For Part 1 Reference)

STRESS

Please rate your average stress level on a scale of 1 to 10 (10 being the highest stress level)

Cause of Stress

Please rate your energy level on a scale of 1 to 10 (10 being the highest energy level)

Worst Time

Best Time

SLEEP

Average hours of sleep per night?

Please tick the box if you have any of the following sleep patterns

Wake up unrefreshed

Trouble falling asleep

Trouble staying asleep

Wake often

Wake early

Difficulty waking

EXERCISE

Do you currently exercise?

If yes, please indicate type of exercise, frequency per week and duration

YOGA

Do you currently practice yoga?

If yes, please indicate type of yoga, frequency per week and duration

INJURIES

Have you had any previous injuries like fractures / sprains / strains?

If yes, please list bone / muscle / ligament affected and year it happened

PLEASE TICK THE BOX IF YOU HAVE ANY OF THE FOLLOWING

Liver/Gall Bladder

Pale / clay colored stools

History of jaundice

History of Hepatitis A

Unexplained itching

Fatty foods cause indigestion and nausea

Yellowish discolouration eyes

Immunity

Colds / Flus

Frequent infections

Allergies / hay fever

Thrush

Cold sores

Ear, Nose and Throat

Sore throat

Tonsillitis

Ear infections

Sinusitis

Tinnitus

Allergies / hay fever

Respiratory

Emphysema

Cough

Pneumonia

Asthma

Difficulty breathing

Bronchitis Wheezing / shortness of breath

Musculoskeletal

Aches and pains

Joint pain

Joint swelling

Muscle cramps / twitching

Headaches

Disc herniation / protrusions

Sciatica

Cardiovascular

High blood pressure

Low blood pressure

High cholesterol

Arrhythmia

Stroke Dizziness

Chest pain

Breathlessness on exertion

Leg pain on exertion

Palpitations

Cold hands and feet

Easy bruising

Varicose veins

Nose bleeds

Urinary

Frequent urination

Dribbling urine after urination

Strong and sudden urge to urinate

Frequent bladder infections

Blood in urine

Pain or burning urination

Getting up at night to urinate

Poor urine stream

Incontinence

Mucous in urine

Skin

Acne

Eczema

Dermatitis

Poor wound healing

Dry skin

Dandruff

Upper Digestion

Heartburn / acid reflux

Indigestion

Burping

Stomach pain

Sense of fullness after eating

Nausea / vomiting

Lower Digestion/Bowel Health

Irritable bowel syndrome

Crohn’s disease

Ulcerative colitis

Excess gas or bloating

Lower abdominal pain / cramping

Haemorrhoids

Polyps

Stools hard/dry

Stools loose / watery

Stools float

Stools sink

Blood / mucous in stools

Undigested food in stools

Regular laxative use

How often do you have a bowel movement?

Emotional State

Feelings of anxiety

Panic attacks

Frequent sad thoughts

Pessimistic / negative thoughts

Feelings of guilt

Difficulty concentrating

Nervousness

Change in appetite

Metabolic

Sugar cravings

Weakness

Fatigue

Dry skin

Brittle hair

Weight gain

Weight loss

Sensitive to heat

Sensitive to cold

Increased thirst

Anaemia

FOR WOMEN

Indicate cycle length and duration of bleed

At what age did you get your first period?

Do you get blood clots in your period? Please note size (eg: 10c piece, 50c piece, etc.)

Do you use?

Pads

Tampons

'Moon’ cups

Are these..

Organic

Non-organic

Reusable

Are you planning to conceive within the next 12 months?

Tick the boxes that apply to you

PMS / PMT

Painful periods

Breast tenderness

Bloating

Fluid retention

Irregular cycles – long or short

Ovarian cysts

Fibroids

Endometriosis

Amenorrhoea

PCOS

Excess facial hair / acne

Vaginal discharge

Heavy bleeding

Menopausal problems

Hysterectomy

Hot flushes

History of miscarriage

Currently pregnant

Currently breastfeeding

Abnormal pap smear

Thrush or vaginal itching

Vaginal dryness

Cystitis

History of STI’s

Low libido

Pregnant and/or breastfeeding

FOR MEN

Tick the boxes that apply to you

Prostate issues

Low libido

Pain or swelling in groin/testes

History of STI’s

Difficulty sustaining an erection

Difficulty urinating

Poor beard or hair growth

Is there anything else you’d like to mention that hasn’t already been covered? If yes, please list here.

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