Shopping Cart
Your Cart is Empty
There was an error with PayPalClick here to try again
CelebrateThank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart

Whole Health Assessment

Whole Body Symptoms (ROS):

GENERAL Body: burned out feeling, decreased stamina, difficulty falling asleep, difficulty staying asleep, excessive energy, can’t calm down, decreased motivation, addictive behavior (sex, food, alcohol, drugs),increased aging

EYES, EARS, NOSE, THROAT:  vision changes, hearing decreased, ringing in ears, hoarseness, neck fullness, bulging eyes, dental problems, hoarseness, ear pain, ear fullness, sinus issues, hay fever, 

-MOUTH: Amalgam fillings, root canals, deep cleaning, gingivitis, tooth extractions, crowns, dentures, tooth pain, jaw pain, broken teeth, visable tooth decay, cavities, 

CARDIAC: cold extremities, elevated blood pressure, low blood pressure, irregular heartbeat, heart palpitations, slow pulse rate

RESPIRATORY: breathing difficulties, asthma history, easily short of breath, phlegmy cough, congestion, tickle cough

GASTROINTESTINAL:  heartburn, acid reflux, bloating, abdominal discomfort, milk intolerance, gluten sensitivity, constipation, loose stools, nervous stomach, increased farting, increased burping

GENITOURINARY: fluid retention, low libidio, high libido, urinary frequency, urinary incontinence, infertility problems

Females: vaginal dryness, irregeg periods, uterine fibroids, PCOS, ovarian cysts,t ender breasts, fibrocystic breasts, increased facial hair, increased body hair, last period:_____ Birth control method:_______________

Men: decr’d urine stream, increased urinary urge, prostate enlargement, Erectile issues, premature ejaculation

ENDOCRINE:  exhausted, morning fatigue, afternoon tiredness, evening tiredness, energized at bedtime, sweating, night sweats, sugar cravings, hot flashes, hair falls out easily, excessive hair growth, brittle hair, scalp hair loss, unintentional weight loss/gain

SKIN: frequent breakouts, acne problems (face, back, chest) very dry skin; nails are thin, peel, or break easily; bruise easy, thinning skin, Rosacia, eczema, red patches, nail fungus, skin easily red or flushed

MSK: muscle/joint aches & pains, stiffness, fibromyalgia, decreased strength, decreased muscle mass, bone loss, fractured bones, head injury, whiplash history, stiff/tense neck & shoulders, decreased head pivot

NEURO: decr mental sharpness, memory issues, regular headaches, frequent migraines, dizziness, light-headed, seizure history, tremors, easily overstimulated, Forgetfulness, Focus/Concentration issues, Distractible

PSYCHIATRIC: stressed, overthinking, excessive worry, nervous, difficulty concentrating, forgetfulness, tearful, depressed, mood swings, OCD type behavior, poor impulse control, can’t turn off brain, isolating behaviors

IMMUNE: allergies, food sensitivities, recent antibiotics, recent infections, catch colds/flus every 1-2 months, history of anaphylaxis to foods/medicines, dental problems, COVID illness, Cancer history

LABS:  high blood sugars, hypoglycemia, high A1C, high cholesterol, abnormal Vitamin D3, thyroid problems, Abnormal B12 levels, Abnormal MTHFR, history of anemia, Diabetic, liver disease, heart disease

Surgical History:  Tonsillectomy, Appendectomy, Ear tubes placed, thyroid, wisdom teeth, other: __________

Strenuous Exercise

Poor Immune Health

Busy/Stressful Life

Inflammatory Habits

Wellness-Illness Assessment

Wellness-IIlness Map (circle symptoms, briefly answer questions)

Psychiatric Symptoms: Depression, Anxiety, Insomnia, Mania, Irritability, Psychosis, Compulsions, Inattention, Brain Fog, Fatigue, headaches, Impulsivity, Self-harm, Hostility, Overthinking, Easily upset, Difficulty with schedule changes, Apathy, Low motivation


-What are your Relationships like?
--How healthy is your communication within your relationships?
-Do you experience feelings of isolation?
-What is your attachment style? What is your partner's attachment style?

-What are your Sleep patterns like? Do you stay up late then wake later? Do you take anything to help you sleep?
-Do you struggle with falling asleep, staying asleep, Insomnia, circadian rhythm disruptions, or sleep apnea?

-What  do you use to help you manage your moods? 

-____ hours/day screen time, Avoid stress/problems/bills, Binge eating (continuing to eat after you are full)
-restrictive eating (skipping meals, limiting size of meals, limiting types of foods you'll eat, other:
-Regular Marijuana use to relax, cope with stress, manage your moods, have "fun", deal w/anxiety, other;
-Alcohol use: avoid, use regularly, to relax, help with sleep, calm down, decrease social anxiety, to have "fun", other:

--number of drinks tend to have in a session: 0 1 2 3 4 5 6 7 8; 
--types of drinks you enjoy: cocktails, hard seltzer, beer, wine, whiskey, bourbon, other:

Nutrition/Eating Habits:

-Eating Habits: Breakfast: none, small, med, large; Lunch: none, small, med, large; Dinner: small, Med, Large; Overeat, Restrict, Binge

-What kinds of foods do you eat?
-Dietary Preferences: Standard diet, Vegan, Lacto-ovo vegetarian, Pescatarian,  Keto, Paleo, Whole Foods, Gluten free, Casein Free, Fodmap

-Do you eat organic foods often?

-Alcohol use: none, rare, several times week, on weekends; wine, beer, cocktails, cider; average number of drinks in a session: _______

Toxic exposure risk: 

-pollution, mold, non-organic foods, processed foods, High fructose corn syrup, Sodas, alcohol, nicotine, smoking

-Detox practices: Steam sauna, infared sauna, hyperbarics, cold therapy, fasting, intermittent fasting, other:______________________.
-Food Sensitivities: Nuts, Sugar, Soy, Corn, Gluten, Wheat, Dairy, Eggs, Shellfish, Seafood, Chicken, Red meat, other:
-Allergies: Metals, plastics, chemicals, perfumes, Gluten, Soy, corn, Casein, Iodine, Shellfish, Stone fruit, Peanuts, Tree nuts, Coconut

Physical Activity/Exercise:

-Flexibility: Low, medium, High;  Muscular Strength:  low, medium, high; Endurance: Low, medium, high; Heart rate variability: __________.
-Types of Exercise: stretching, yoga, pilates, walking, jogging, running, swimming, 


Learning: No problems. Slow to read. Math difficult. Higher math impossible. Auditory learner. Kinetic learner. Read to learn.

Trauma: childhood, adolescence, adult; exposure to domestic violence, assault, neglect, accident, witness/victim of crime, bullied
-Early significant loss in childhood or adolescence; Betrayal of significant other/friend, 
-Symptoms: zoning out, losing time, memory triggers, physical reaction: heart racing, feeling stuck, feeling "in your head", freeze, flight
Beliefs-Political thoughts, disempowerment, values,


-Faith foundation: Agnostic, Atheist, Buddhist, Catholic, Evangelical, Jewish, Muslim, Universalist, New Age, Unsure

-spiritual betrayal, spiritual abuse; faith pursuit, making meaning, search for truth/meaning, other:

-Grief/loss: significant loss: friend, family, pet; cont to feel: numb, anger, bargaining, acceptance, disconnection


Gut-Brain Axis: Gastrointestinal Dysbiosis, Microbiome, 

-Leaky Gut (bloating, gas, rapid transit, constipation, allergies, skin issues, antibiotics, infection)

Metabolic-Regulation: Thyroid issues (Hypo/Hyper thyroid, Grave's disease, Hashimotos); Insulin Resistance, Hypoglycemia, Diabetes,

Difficulty losing weight, Hair thinning (eyebrows, scalp); weight gain around waist/hips

-Hormone imbalance (Estrogen, Progesterone, Testosterone, Insulin

Genetic Dysfunction: MTHFR, APOE4

Cancer: Brain, Breast, Blood, Bladder, Bone, Ovarian, Uterine, Prostate, Colon, Thyroid, 

Brain Optimization: 

-Head injury/TBI: minor injury, concussion, post concussion symptoms: sleep issues, irritability, word-finding, expressive issues, ADHD  -Mitochondrial dysfunction, Neurodegenerative changes (slowed recall, memory, cognition, 

Immune modulation: Infectious, autoimmune, inflammation

Detoxification: Metals, Molds, metabolites