Personal Health Review Intake Form

Personal Health Review intake form

Before Your Session

Please take a few minutes to complete this form before your appointment.

This gives me a clearer picture of what’s going on for you ahead of time, so we can use our session to focus on what matters most rather than starting from scratch.

There are no right or wrong answers — just answer as honestly as you can based on where you are right now.

You don’t need to write a lot. A few clear thoughts are enough.

If something feels important but isn’t asked here, feel free to include it in the final question.

Once you’ve completed the form, you’re all set for your session.

First name

Last name

Birthday

Year

Month

Day

What feels most off for you right now? (Briefly describe what brought you here)

When did you first notice this starting?

Has this been constant, or does it come and go?

What have you already tried? (Include anything — products, supplements, lifestyle changes, etc.)

What has helped, even slightly?

How is this affecting your day-to-day life? (sleep, energy, mood, focus, etc.)

How is your sleep currently? (hours + quality)

How is your energy through the day?

What does stress feel like in your body? (tension, digestion, emotions, etc.)

What does a typical day of eating look like for you?

Do you feel your body is responding differently than it used to?

What are you hoping to gain from this session?

Is there anything else you feel is important for me to know?

Return to Balance — Understand What Your Body Needs and How to Support It