NAME *

First Name

Last Name

PHONE *

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APPETITE

Irregular each day

Frequently hangry

Currently reduced

Always steady

DIGESTION PATTERN

Irregular / Gas and bloating

Quick / indigestion / acidity

Sluggish/ often feel full with little food

BOWEL MOVEMENT

2-3 times a day

Once a day

Variable each day

3-4 times a week

High constipation

Does not feel fully emptied

STOOLS OFTEN

Dry / hard/ blackish or dark brown

Loose / yellow / burning sensation

Heavy / well-formed/ with mucus

SLEEP PATTERN

Often broken

Keep chasing

Often drowsy

Sound

DREAM PATTERN

Many dreams

Less or no dreams

Dreams of chasing / fearful / anxiety-provoking

Dreams of fighting / wars / fire

Dreams of romance / water

BODY-WEIGHT

Underweight

Overweight

Often fluctuating

Prefer losing some body-fat

At optimal weight

Don't care

DAILY ENERGY LEVELS

Exhausts quickly

Exhausts from excessive thinking

Always low

Frequent fatigue

Always high

COMMON EVERYDAY THEME

Tired on waking up

Fresh in morning

Sleepy after eating

Aches, pains by evening

Switched-on whole day

OFTEN GET

Cold-flu

Inflammation

Infections

Allergies

Routinely healthy

EYES OFTEN

Dry / restless / frequently blinking

Red / hypersensitive to light

Pale / excessive lacrimation / sticky

MOUTH

Often dryness / receding gums

Red / inflamed and tender gums

Excessive salivation

TEETH

Cavities / cracked enamel / brittle

Yellow / sensitive to sour taste

Strong / healthy enamel

SKIN

Never any issues

Oily / smooth / thick-ish

Acne / pimples / rashes / itchy

Dry / rough / scaly

Other skin conditions

JOINTS

Cracking / popping / noisy

Tender / feel inflamed

Swollen

Often strong and healthy

Stiff / limited movement

Too much flexibility

DAILY STRESS / ANXIETY LEVELS (10=take medications)

0-2

3-4

5-7

8-9

10

EMOTIONS

Often able to control

Hide or suppress

Express out assertively

Difficult to control

Routine mood swings

Never thought about it

THOUGHTS

Brain fog, want more clarity

Often negative

Clear and precise thinking

Often positive, optimistic

Random uncontrolled thoughts

Rumination

TENDENCY TO OFTEN FEEL

Anxious/ fearful / worried

Angry / short-tempered / critical / jealous

Lonely / low / depressed / greedy

SEXUAL CHARACTERISTICS

Optional unless relates to health condition

Often premature ending

Painful intercourse

Low libido

Healthy orgasms

High sex drive

Avoid sex as often as can

SPIRITUAL INCLINATION

Meditate regularly

Strong faith

Believe in Higher Power but non-religious

Wish to meditate more

Don't believe in anything

Believe only in humanity

EXERCISE ROUTINE

Don't exercise

Yoga / pilates

Walking / hiking

Cycling / swimming

Gym work / boot-capms

Running / Triatholons

Wish to exercise

Ad-hoc exercise

SELF-CARE

Don't believe

Regular

Ad-hoc

Wish-list

HEALTH GOALS (Select Top 5)

Recovery from existing physical / mental health condition (Pl provide details below if wish)

Detox and cleansing

Hormonal balance

Fertility

Menstrual health

Delay ageing, better skin health

Weight management / body-fat reduction / fitness

Stress/ anxiety reduction / management

Re-balance, re-align, reset

Immunity / vitality / energy

Pain relief and management

Strength and flexibility

Improving digestion

Better diet and healthier lifestyle

Sleep enhancement

Sexual / reproductive health

Overcoming trauma, distress, suppressed emotions

Better control over thoughts and emotions

Freedom from habits, addictions, limitations

Improvement in relationship with self

Improve relationship with others

Spiritual balance / connection

Start some form of Meditation / Breath-work

Other goals (Pl mention below)

YOUR BIOLOGICAL AGE

Below 25

26-35

36-45

46-55

55-65

65 +

YOUR 'FEEL LIKE' AGE

Based on self-assessment of your strength, stamina, energy levels and attitude towards life

Below 25

26-35

36-45

46-55

55-65

65 +