Personal Information

Full Name *

Date of Birth

Phone

Email *

Address

City

Province / State / Country

Referred by

Appointment Date

2

Health Goals & Primary Concerns

What brings you here today? Top 1–3 health goals?

When did these concerns begin?

Overall Health Score Right Now

1 (poor) 10 (excellent) 5

What would a 10 look like for you?

3

Medical History

Current or past diagnosed conditions:

Other conditions:

Past surgeries or significant procedures (include dates):

4

Medications & Supplements

Current prescription medications:

Vitamins, minerals, herbs, or other supplements:

Antibiotic use history:

5

Metabolic & Hormonal Health

Current weight (optional)

Weight 1 year ago (optional)

Height

Blood type (if known)

Weight history:

Energy patterns throughout the day:

Do you experience any of the following?

For women — menstrual & reproductive history:

Hormone therapy or hormonal herbs (current or past):

6

Gut & Digestive Health

Bowel movement frequency:

1–2 times/day (ideal) 3+ times/day Every other day Less than every other day

Stool consistency:

Hard / pellet-like Formed & easy to pass (ideal) Loose / mushy Watery / urgent

Digestive symptoms:

Food allergies, intolerances, or foods you avoid:

Significant gut infections or food poisoning history:

7

Nutrition & Lifestyle

Describe a typical day of eating:

Current dietary approach:

Other dietary approach:

Percentage of meals home-cooked:

Less than 25% 25–50% 50–75% 75–100%

Foods regularly consumed:

Foods you crave:

8

Sleep

Average hours of sleep

Usual bedtime

Sleep concerns:

Additional sleep notes:

9

Stress & Nervous System

Current stress level

1 (none) 10 (extreme) 5

Primary source of stress:

How do you currently manage stress?

Significant trauma or adverse life events affecting your health today:

Type of exercise

Frequency per week

10

Mental Health & Mood

Current mood concerns:

Additional notes:

11

Environmental Exposure

Known exposures:

Additional notes:

12

Family Health History

Conditions in immediate family:

Additional family health patterns:

13

Current Health Team & Recent Testing

Other practitioners you are currently seeing:

Most recent lab work or testing:

14

Your Health Story

This is the most important section. Take your time. Your whole story matters here.

At what point in your life did you feel your best, and what was different then?

Is there anything else — physical, emotional, or contextual — important for me to understand?

What does success look like for you 90 days from now?

15

Readiness & Support

How ready are you to make lifestyle changes?

Very ready — I'm committed Ready but need guidance Somewhat ready — have some barriers Still exploring

Support at home:

Yes — family / partner on board Somewhat Navigating independently

Anything that might get in the way?

Anything else you'd like Lisa to know?

Confidentiality: All information is strictly confidential and used solely to support your health. By submitting you consent to Lisa Watson using this information for your consultation.

Welcome — Let's Read Your Whole Story