Name
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First Name
Last Name
Email
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Phone
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Country
(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birth Date
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Place of Birth
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Biological Sex
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Male
Female
Occupation
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Today's Date
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MM
DD
YYYY
Describe Your Problem(s):
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What treatments have you tried?
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Has anything been successful? Please explain.
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With whom do you live?
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Any pets or farm animals? If so, where do they live?
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Have you lived or traveled outside of the U.S. or Canada? If so, when and where?
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Have you or your family recently experienced any major life changes? If so, please explain.
Have you experienced any major losses in life? If so, please comment.
How much time have you missed out on from work or school in the past year?
Please list any previous jobs you have worked.
Did you feel safe growing up?
Have you been involved in abusive relationships in your life?
Was alcoholism or substance abuse present in your childhood home, or is it present in your current relationship?
Do you feel safe, respected, and valued in your current relationship?
Have you had any violent or otherwise traumatic experiences, or have you witnessed violence or abuse?
Would you feel safer discussing any of the above issues in private? Are there issues you'd prefer not to discuss at all?
Please list medical and surgical history.
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Please list previous hospitalizations.
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How often have you taken antibiotics?
How often have you taken oral steroids?
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What medications are you taking now?
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Please list all vitamins, minerals, and other nutritional supplements you are taking now.
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Were you a full term baby or born prematurely? Were you breast fed or bottle fed?
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As a child, did you eat a lot of sugar and/or candy?
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What does your typical daily diet look like?
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How much of the following do you consume each week:
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Tea, coffee, soda, other caffeine, cheese, other dairy, bread, sugar, candy/chocolate, dessert
Are you on a special diet? If so, is there anything about it that we should know?
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Do you have symptoms immediately after eating? If so, are they associated with any particular food or supplement(s)?
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Examples: bloating, belching, hives, sneezing, etc.
Do you feel much worse when you eat certain foods?
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Do you feel much better when you eat certain foods?
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Does skipping a meal greatly affect your symptoms?
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Have you ever had a food that you really craved or "binged" on over a period of time?
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Do you have an aversion to certain foods? If so, which foods?
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How many bowel movements do you have per day?
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Do you have any constipation or diarrhea?
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Constipation is considered straining and/or less than 1 bowel movement per day.
Do you have intestinal gas? If so, when?
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How many times per week do you drink alcohol?
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Have you ever used recreational drugs?
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Have you ever used tobacco? If so, when? For how long?
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Are you exposed to second hand smoke regularly?
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Do you have any mercury amalgam fillings in your teeth? If so, how many?
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Do you have any artificial joints or implants? If so, which ones?
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Do you feel worse at certain times of the year?
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Have you, to your knowledge, been exposed to toxic metals at your job or at home?
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Do odors affect you? If so, which ones?
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Have you ever tried therapy or counseling?
Are you currently married, or have you ever been married?
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Please list your hobbies and leisure activities.
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Do you exercise regularly? If so, what type of exercise?
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If you answered "yes" to the previous question, how many times per week do you exercise?
Do your parents or siblings have (or have they ever had) health issues? Please explain.
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Why do you think you would be a good candidate for Integrative Health Coaching at The North Star Body?
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Which of the following is MOST important to you when it comes to coaching?
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Anything else you'd like us to know?
