MEDICAL & NUTRITION QUESTIONNAIRE

    PART A: BASIC PERSONAL INFORMATION

    1. Full name*

    2. Date of birth*

    3. Sex*

    4. Email*

    5. Phone*

    REFERRAL SOURCE

    How did you find us?*

    If other, please specify:

    PART B: MEDICAL HISTORY & SYMPTOMS (BY SYSTEM)

    1. Metabolic & Hormonal System

    1. Have you been diagnosed with diabetes mellitus?

    If yes, when?

    2. Do you have prediabetes or insulin resistance?

    3. Do you have a history of hypothyroidism?

    4. Do you have a history of hyperthyroidism?

    5. Have you had unexplained weight gain or loss?

    6. Do you experience hair loss, dry skin, or cold intolerance?

    7. Do you experience tachycardia or hyperactivity?

    8. Are you sensitive to cold or heat?

    2. Cardiovascular System

    9. Do you have or have you had hypertension?

    10. Do you have or have you had hypotension?

    11. Do you have or have you had high cholesterol?

    12. Do you have a history of cardiac arrhythmia?

    13. Do you experience shortness of breath or chest pain?

    14. Do you have a history of myocardial infarction?

    3. Nervous System & Energy

    15. Do you often feel fatigued?

    16. Do you wake up tired?

    17. Do you experience “brain fog”?

    18. Do you have difficulty with concentration or memory?

    19. Do you get headaches or migraines?

    20. Do you have insomnia or sleep disturbances?

    21. Do you sleep more than 9 hours and still feel tired?

    4. Respiratory System

    22. Do you have asthma or allergic bronchitis?

    23. Do you have a chronic cough or phlegm?

    24. Do you frequently get respiratory infections?

    25. Do you have a history of pneumonia?

    5. Digestive System

    26. Do you have a history of food intolerances?

    If yes, which?

    27. Do you have a history of stomach issues?

    28. Do you feel bloated after meals?

    29. Do you feel your digestion is slow?

    30. Do you have gas or bowel sounds after eating?

    31. Do you have bowel movements less than once per day?

    32. Do you have diarrhea or irregular stools?

    33. Do you alternate between constipation and diarrhea?

    34. Do you feel incomplete evacuation?

    35. Do you experience nausea or vomiting?

    36. Do you have bad breath?

    37. Do you have Irritable Bowel Syndrome?

    38. Do you have ulcerative colitis or Crohn’s?

    39. Have you been diagnosed with leaky gut?

    6. Skin & Detoxification

    41. Do you have skin issues?

    42. Changes in skin/hair?

    43. Adult acne or hair loss?

    44. Do you sweat easily or not at all?

    45. Poor tolerance to deodorants/perfumes?

    46. Do you have cellulite or fluid retention?

    47. Difficulty tolerating toxins?

    7. Musculoskeletal System

    48. Joint pain or muscle aches?

    49. Neck or back pain?

    50. Joint inflammation?

    51. Wake up stiff?

    52. History of injuries or surgeries?

    If yes, details:

    53. Manual labor or physical strain?

    8. Immune System & Autoimmunity

    54. Frequent viral illnesses?

    55. Autoimmune condition?

    If yes, which?

    56. History of long COVID?

    57. Do you have allergies?

    If yes, which?

    58. Sensitive to medications or chemicals?

    9. Reproductive & Urinary System
    A. For All (Men & Women)

    59. Pain/burning during urination?

    60. Urinate frequently?

    61. History of urinary tract infections?

    If yes, how many per year?

    62. Urinary incontinence?

    63. Incomplete bladder emptying?

    64. Changes in urine color/odor?

    65. History of kidney/bladder stones?

    66. History of STIs?

    If yes, which?

    B. Women

    67. Age at first period?

    68. Cycle regular?

    69. Painful periods?

    70. PMS symptoms?

    71. Bleeding outside cycle?

    72. Ovarian cysts/fibroids/endometriosis?

    73. Perimenopausal/menopausal? Age?

    74. Hot flashes, dryness, libido changes?

    75. History of miscarriages, infertility?

    76. Have you been pregnant?

    If yes, how many pregnancies and weight gain?

    78. Do you have children? How many?

    C. Men

    79. Erectile difficulties?

    80. Libido changes?

    81. Pain in testicles/groin?

    82. Discomfort during ejaculation?

    83. History of prostatitis?

    84. Changes in erection quality?

    85. PSA test or prostate ultrasound?

    10. Neurological & Cognitive

    86. Frequent headaches?

    87. Brain fog?

    88. Reduced memory?

    89. ADHD-like symptoms?

    90. Tremor or clenching?

    91. Feel on edge without reason?

    92. Sensitive to noise/light?

    11. Psychosocial / Emotional Regulation

    93. Anxiety or panic?

    94. Depression?

    95. Mood swings?

    96. Excessive daily stress?

    97. Lack of purpose?

    98. Guilt/shame?

    99. Burnout?

    100. Panic attacks / psychiatric treatment?

    12. General – Medical

    101. History of cancer?

    102. Chemotherapy or radiation?

    103. Contraceptives or hormonal meds?

    104. Long-term medication?

    If yes, which?

    PART C: NUTRITION HISTORY & HABITS

    1. Diet Type

    1. Have you been on a weight-loss diet in the last 2 years?

    2. Have you had major weight fluctuations?

    If yes, between which weights?

    3. Do you follow a specific diet? (e.g., keto, vegan, fasting)

    4. Have you ever tried a ketogenic diet?

    5. Have you done detoxes / juice cleanses / fasts?

    6. Do you follow any religious/ideological dietary pattern?

    7. What has been your lowest and highest adult weight, and at what ages?

    2. Eating Habits

    8. How many meals per day do you usually eat?

    9. Do you regularly skip breakfast?

    10. Do you eat late at night (after 9 p.m.)?

    11. Do you eat in front of screens (TV, phone, computer)?

    12. Do you chew your food well?

    13. Do you feel satisfied after meals, or do you overeat?

    14. Do you snack frequently during the day?

    3. Diet Quality

    15. Do you often eat ready-made/processed foods?

    16. Do you consume fresh fruit daily?

    17. Do you eat vegetables with every meal?

    18. Do you consume whole-grain products?

    19. Do you often eat red meat?

    20. Do you consume fish or seafood at least 2x/week?

    21. Do you drink fresh juices or smoothies?

    22. Do you buy organic products?

    23. How often do you eat sweets, baked goods, or snack foods?

    4. Drinks & Fluids

    24. How much water do you drink per day?

    25. Do you drink coffee?

    If yes, How many per day?

    26. Do you consume energy drinks or soft drinks with sugar/sweeteners?

    27. Do you drink alcohol?

    If yes, how many times per week?

    28. Do you drink herbal teas/infusions?

    5. Sensitivities & Intolerances

    29. Have you ever had intolerance or gut testing?

    30. Are you sensitive to gluten?

    31. Are you sensitive to lactose or dairy products?

    32. Do you have known food allergies or intolerances?

    33. Have you noticed certain foods cause discomfort?

    If yes, which?

    6. Supplements

    34. Do you regularly take dietary supplements?

    35. Have you ever received intravenous vitamins (IV drips)?

    36. Do you consult a professional about supplements or choose them yourself?

    37. What types do you take (e.g., vitamins, minerals, probiotics)?

    7. Relationship with Food

    38. Do you have a history of binge-eating episodes or food control issues?

    39. Do you crave sweets or carbohydrates at specific times?

    40. Do you feel guilty after certain meals?

    41. Do you eat when stressed, sad, or tired?

    42. Do you have a history of anorexia nervosa or bulimia?

    PART D: LIFESTYLE

    1. Sleep

    1. Do you sleep enough (7–8 hours)?

    2. Is your sleep good quality (without interruptions)?

    2. Physical Activity

    3. Do you move/exercise regularly?

    4. How many hours per day do you sit?

    3. Stress & Lifestyle

    5. How much daily stress do you feel?

    6. Do you use screens before bedtime?

    7. Do you have wellness rituals (e.g., journaling, sauna, walks)?

    8. Do you spend time in nature?

    9. Do you feel you live with purpose/meaning?

    PART E: EXERCISE & PHYSICAL ACTIVITY

    1. Regular Exercise

    1. Do you exercise regularly?

    2. Exercise Details

    2. How many times per week?

    3. What type of exercise?

    4. How long does each session last?

    5. How do you feel after exercising?

    6. Do you have a history of overtraining or injuries?

    PART F: GENETIC & FAMILY HISTORY

    A. Family History (Blood Relatives)

    1. Type 2 diabetes

    2. Heart disease or hypertension (under age 60)

    3. Stroke or thrombosis

    4. Autoimmune diseases (e.g., Hashimoto’s, SLE, Rheumatoid Arthritis)

    5. Alzheimer’s disease or other dementias

    6. Cancer (any type)

    If yes, please specify:

    7. High cholesterol/lipids or familial hyperlipidemia

    8. Depression, anxiety disorder, or psychiatric diagnosis

    9. Osteoporosis or severe arthritis

    10. Obesity or metabolic syndrome

    11. Infertility or endometriosis

    12. Longevity (over 90 years)

    If yes, who?

    PART G: PRIORITIES & GOALS

    1. What are your top health/body goals? (maximum 3)

    2. What is the most important change you wish to achieve in the next 3 months?