This is just the beginning!

I hope you are excited! If you could fill out the information below, that would be awesome. It helps me in preparing for your appointment!

Let me know if you have any questions.

In the meantime, enjoy this gift!

Do you or have you experienced any of the following in the past 6 months....

Part 1

Feeling wired yet tired?
Difficulty falling asleep or disrupted sleep?
A feeling you're constantly racing from one task to the next?
A struggle calming down before bedtime, or a second wind that keeps you up late?
A feeling of anxiety or nervousness- can't stop worrying about things beyond your control?
A quickness to feel anger or rage- frequent screaming or yelling?
Memory lapses or feeling distracted, especially duress (threat)?
Decreased Fertility?
Sugar cravings (a sweet tooth after each meal)?
Increased abdominal circumference?
Skin conditions such as eczema or thin skin?
Bone loss?
High blood pressure?
Rapid heartbeat?
High Blood Sugar?
Indigestion, ulcers, or GERD?
More difficulty recovering from physical injury than in the past?
Unexplained pink to purple stretch marks on back or belly?
Irregular Menstrual cycle?

Part 2

Fatigue or burn out (have to use caffeine to increase energy)?
Loss of stamina, particularly in the afternoon between 2-5 PM?
An atypical addiction to negative point of view?
Crying bouts for no particular reason?
Deceased problem solving ability?
Feeling stressed most of the time?
Decreased ability to handle stress?
Insomnia or difficulty staying asleep between one and four in the morning?
Feel dizzy upon standing?
Difficulty fighting infection?
Asthma? Bronchitis? Chronic cough? Allergies?
Salt craving?
Excess sweating?
Nausea, vomiting, or diarrhea? Or loose stools alternating with constipation?
Muscle weakness, especially around knees? Muscle or joint pain?
Hemorrhoids or varicose veins?
You bruise easily?
A thyroid problem that's been treated and you feel better, but suddenly feel palpitations or rapid irregular heartbeat?

Part 3

Agitation or PMS?
Cyclical headaches (around menstuation or ovulation)?
Painful or swollen breast?
Irregular mestrual cycles or cycles becoming more frequent?
Heavy or painful periods?
Bloating, particularly in the ankles and belly?
Gain weight before period?
Ovarian cyst, breast cyst, or endometrial cyst (polyps)?
Easily disrupted sleep?
Itchy or restless legs, especially at night?
Increased clumsiness?
Infertility?
Miscarriage in the first trimester?

Part 4

Bloating, puffiness, water retention?
Abnormal pap smears?
Heavy bleeding or postmenopausal bleeding?
Rapid weight gain in butt and hips?
Increased bra-cup size or breast tenderness?
Fibroids?
Endometriosis or painful period?
Mood swing, PMS, depression, or just irritability?
Weepiness, sometimes over ridiculous things?
Mini breakdowns? Anxiety?
Insomnia?
Brain fog?
Red flush on face (rosacea)?
Gallbladder problems?

Part 5

Poor memory?
Emotional fragility?
Depression, perhaps with anxiety or lethargy?
Wrinkles (your face creams no longer work)?
Night sweats and hot flashes?
Trouble sleeping, waking up in the middle of the night?
Leaky or overactive bladder?
Droopy breast or breast lessening in volume?
Bladder infections?
Sun damage more obvious?
Achy joints?
Loss of interest to exercise?
Recent injury (wrist, shoulders, low back or knees)?
Bone loss?
Vaginal dryness, irritation or loss of feeling?
Lack of juiciness elsewhere (dry eyes, skin, etc.)?
Painful sex?
Low libido?

Part 6

Excessive hair on face, chest, or arms?
Acne?
Greasy skin and/or hair?
Thinning head hair?
Discoloration of your armpits?
Skin tags?
Hyperglycemia or hypoglycemia?
Depression? Anxiety?
Reactivity and/or irritability, or excessively aggresive episodes?
Menstrual cycle occuring more than thirty-five days?
Ovarian cyst?
Mid cycle pain?
Infertility?
Polycystic ovary syndrome?

Part 7

Hair loss, including the outer third of your eyebrow or eyelashes?
Dry skin?
Dry straw-like hair that tangles easily?
Thin brittle fingernails?
Fluid retention?
Weight you CANNOT lose?
High cholesterol?
Recurrent headaches?
Bowel movements less often than once a day, can't completely evacuate?
Decreased sweating? Muscle or joint aches or poor muscle tone?
Tingling in hands or feet?
Cold hands and feet? Cold intolerance? Heat intolerance?
Sensitivity to cold?
Slow speech?
Slow heart rate?
Lethargy?
Fatigue, especially in the morning?
Slow brain, slow thoughts, difficulty concentrating?
Sluggish reflexes, diminished reaction time, even a bit apathy?
Low sex drive, and you're not sure why?
Depression or moodiness?
On a prescription for the latest antidepressant and you still don't feel like yourself?
Heavy periods or other menstrual problems?
Infertility or miscarriage? Preterm birth?
Enlarged thyroid/goiter? Difficulty swallowing? Enlarged tongue?

Are you currently taking any medication or supplements? If so, what are they?

Do you still experience a period? If so, how often? *

Do you have any past experiences/traumas that you feel could be causing a problem in your body?

Are any of these issues causing problems in your marriage or other relationships? Explain if so.

Are you willing to make the financial and time commitment to see real change? Why or why not? *

What, if anything, do you feel has gotten in your way of healing or getting the result you want?

Are you currently taking any action that is helping or not helping?

What are you most excited to see change as you get yourself in a much better place?

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