Patient Forms

Complete all forms below

Patient Forms

All starred areas are required

Name *

Date *

Email *

Phone

1. DIET DIARY

Please fill in the boxes for what you typically eat for breakfast lunch dinner snacks drinks and any symptoms you experience.

Breakfast

Lunch

Dinner

Snacks

Drinks

Symptoms

Complete Wellness Intake Form Below Then Press The Submit Button

2. WELLNESS INTAKE FORM

Please Indicate the areas of health you want to improve

I have difficulty falling asleeр
Lose Weight
More Energy
Sleep Better
Improve Digestion
Prevent Problems
Anti-Aging Support
Improve General Health

If you could improve just ONE thing about your health, what is the priority?

Cortisol Imbalance Symptom Questionnaire

In the box under each below question assign a number between 0 and 10 (0 being Not True and 10 being Very True)
------------------------------------------

I have difficulty falling asleeр

I wake up throughout the night

I have energy highs and lows throughout the day

I frequently feel "wired" in the evenings

I feel tired all the time

I need caffeine to get going in the morning

I usually go to bed after 10pm

I frequently get less than 8 hours of sleep per night

I get fatigued easily

Things I used to enjoy seem like a chore lately

My sex drive is lower than it used to be

I have been experiencing feelings of depression such as sadness or loss of motivation

If I skip meals I feel low energy or foggy and disoriented

I find that I am easily irritated or upset

I tend to overwork with little time for play or rleaxation for extended periods of time

I crave sweets

I frequently skip meals or eat sporadically

I am experiencing muscle aches and headaches

I have had one or more stressful major life events

3. WEIGHTLOSS PROFILE

1. What are your weight loss goals?

Lose 5 - 15lbs
Lose 16 - 30lbs
Lose 31 - 50lbs
Lose 51 - 100lbs
Lose 100lbs +
I just want to be healthy

2. When do you want to reach your goal weight?

2 Weeks
4 Weeks
12 Weeks
6 Months
1 year

3.What is your commitment level to losing weight?

I'm extremely motivated
High
Average
Low
I need constant encouragement

Do you or someone else in your houehold cook or prepare meals most days of the week?

How Often do you eat out?

I eat out for every meal including weekends
I eat out for every meal during the work week
I eat out on occasion
I rarely eat out

1A. Once you start eating, do you find it difficult to stop?

1B. Do you crave foods such as breads, pastas, baked goods, and chips?

1C. When you eat grains, do you feel tired, sluggish or bloated?

1D. Have you been overweight for one year or longer?

2A. Are you stressed?

2B. Even when you eat healthy and exercise, is it hard for you to lose weight?

2C. Are you concerned about having a sluggish thyroid?

2D. Do you have a problem falling and/or staying asleep at night?

2E. Have you been diagnosed with hyperthyroidism (Over-active thyroid)?

3A. Do you eat at least 25 grams of fiber daily?

3B. Do you skip meals or go more than 4 hours without eating (While awake)?

3C. Do you eat breakfast within 1 hour of waking?

4A. Do you consume quality protein within 45 minutes of exercising?

4B. At every meal including snacks, do you consume protein?

4C. When you lose weight do you feel like you also lose energy and strength?

5A. Do you feel tired, unalert, and lacking energy most days?

5B. Do you feel like you're stuck in a plateau?

5C. Do you feel like your metabolism needs a boost?

5D. Are you sensitive to caffeine or stimulants?

6A. Do you feel like you lose weight slowly?

6B. Do you want to promote reduction in Body Mass Index (BMI)?

7A. Do you have excess fat on your stomach, hips, butt, or thighs?

7B. Do you want help to increase your lean muscle mass?

8. Do you currently take a daily multivitamin supplement?

9. Do you eat 6-12 cups of fresh vegetables daily?

10. Are you allergic to soy?

11A. Do you want help with appetite control and metabolism?

11B. Would you like a healthier alternative to coffee or tea that can also help with weight loss?

11C. Would you like a beverage that is full of healthy polyphenols (antioxidants) and has ingredients to decrease weight and body fat?

4. Initial Symptom Checklist

Use the point scale below to rate your symptoms based on how you've been feeling over the past 30 days and indicate the number in the box below each of the symptoms.

0 = never or almost Never
1 = occasionally have it effect is not severe
2 = occasionally have it effect is severe
3= Frequently have it effect is not severe
4 = Frequently have it effect is severe

--- Digestive Tract ---

Belching

Bloated Feeling

Constipation

Diarrhea

Nausea

Passing Gas

Stomach Pains

Vomiting

--- Head ---

Dizziness

Faintness

Headaches

Insomnia

Light Headedness

--- Nose ---

Excessive Mucous

Hay Fever

Sinus Problems

Sneezing Attacks

Stuffy Nose

--- Ears ---

Drainage From ear

Ear Aches

Ear infections

Hearing Loss

Itchy Ears

--- Joints & Muscles ---

Aches In Muscles

Arthritis

Feeling of Weakness

Limited Movement

Pain in joints

Stiffness

--- Skin ---

Acne

Dermatitus

Eczema

Excessive sweating

Flushing / Hot Flashes

Hair Losses

Hives / Rashes

Itching

--- Emotions ---

Agressiveness

Anxiety / Fear

Depression

Irritability / anger

Mood Swings

Nervousness

--- Lungs ---

Asthma / Bronchitis

Chest Congestion

Difficulty Breathing

Shortness Of Breath

Wheezing

--- Weight ---

Binge Eating

Compulsive Eating

Cravings

Excessive Weight

Underweight

Water Retention

--- Energy & Activity ---

Apathy

Fatigue

Hyper Activity

Lethargy

Restlessness

Sluggishness

--- Mind ---

Confusion

Learning Disabilities

Poor Concentration

Poor Memory

Stuttering / Stammering

--- Eyes ---

Blurred Vision

Dark Circles

Itchy Eyes

Sticky Eyelids

Swollen Eyelids

Watery Eyes

--- Mouth & Throat ---

Canker Sores

Chronic Coughing

Gagging

Often Clear Throat

Sore Throat

Swollen Tounge/Lips/Gums

--- Other ---

Anaphylactic Reactions

Chest Pains

Frequent Illness

Genital Itch

Irregular Heartbeat

Rapid Heartbeat

Urgent Urination

-------------------------------------------

Grand Total

Name

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Complete Wellness Intake Form Below Then Press The Submit Button

Wellness Intake Form

Full Name *

This field is required

Please select the areas of health you would like to improve *

Lose Weight

More Energy

Sleep Better

Improve Digestion

Improve Blood Work

Prevent Problems

Anti-Aging Support

Improve General Health

This field is required

If you could improve just ONE thing about your health, what is the priority? *

This field is required

Cortisol Imbalance Symptom Questionnaire

Next to each question assign a number between 0 and 10

(0 being Not True and 10 being Very True)

I have difficulty falling asleeр * *

This field is required

I wake up throughout the night * *

This field is required

I frequently feel "wired" in the evenings * *

This field is required

I have energy highs and lows throughout the day * *

This field is required

I feel tired all the time * *

This field is required

I need caffeine to get going in the morning * *

This field is required

I usually go to bed after 10 pm * *

This field is required

I frequently get less than 8 hours of sleep per night * *

This field is required

I get fatigued easily * *

This field is required

Things I used to enjoy seem like a chore lately * *

This field is required

My sex drive is lower than it used to be * *

This field is required

I have been experiencing feelings of depression such as sadness or loss of motivation * *

This field is required

If I skip meals I feel low energy or foggy and disoriented * *

This field is required

My ability to handle stress has decreased * *

This field is required

I find that I am easily irritated or upset * *

This field is required

I tend to overwork with little time for play or rleaxation for extended periods of time * *

This field is required

I crave sweets * *

This field is required

I frequently skip meals or eat sporadically * *

This field is required

I am experiencing muscle aches and headaches * *

This field is required

I have had one or more stressful major life events * *

This field is required

Weight Loss Profile

1. What are your weigh loss goals? *

Lose 5 - 15 lbs
Lose 16 - 30 lbs
Lose 31 - 50 lbs
Lose 51 - 100 lbs
Lose 100+ lbs
I just want to be healthy

This field is required

2. When do you want to reach your goal weight? *

2 weeks
4 weeks
12 weeks
6 months
1 year

This field is required

3.What is your commitment level to losing weight? *

I'm extremely motivated
High
Average
Low
I need constant encouragement

This field is required

1. Do you or someone else in your houehold cook or prepare meals most days of the week? * *

Yes

This field is required

2. How often do you eat out? * *

I eat out for every meal including weekends
I eat out for every meal during the work week
I eat out on occasion
I rarely eat out

This field is required

1A. Once you start eating, do you find it difficult to stop? * *

Yes

This field is required

1B. Do you crave foods such as breads, pastas, baked goods, and chips? * *

Yes

This field is required

1C. When you eat grains, do you feel tired, sluggish or bloated? * *

Yes

This field is required

1D. Have you been overweight for one year or longer? * *

Yes

This field is required

2A. Are you stressed? * *

Yes

This field is required

2B. Even when you eat healthy and exercise, is it hard for you to lose weight? * *

Yes

This field is required

2C. Are you concerned about having a sluggish thyroid? * *

Yes

This field is required

2D. Do you have a problem falling and/or staying asleep at night? * *

Yes

This field is required

2E. Have you been diagnosed with hyperthyroidism (Over-active thyroid)? * *

Yes

This field is required

3A. Do you eat at least 25 grams of fiber daily? * *

Yes

This field is required

3B. Do you skip meals or go more than 4 hours without eating (While awake)? * *

Yes

This field is required

3C. Do you eat breakfast within 1 hour of waking? * *

Yes

This field is required

4A. Do you consume quality protein within 45 minutes of exercising? * *

Yes

This field is required

4B. At every meal including snacks, do you consume protein? * *

Yes

This field is required

4C. When you lose weight do you feel like you also lose energy and strength? * *

Yes

This field is required

5A. Do you feel tired, unalert, and lacking energy most days? * *

Yes

This field is required

5B. Do you feel like you're stuck in a plateau? * *

Yes

This field is required

5C. Do you feel like your metabolism needs a boost? * *

Yes

This field is required

5D. Are you sensitive to caffeine or stimulants? * *

Yes

This field is required

6A. Do you feel like you lose weight slowly? * *

Yes

This field is required

6B. Do you want to promote reduction in Body Mass Index (BMI)? * *

Yes

This field is required

7A. Do you have excess fat on your stomach, hips, butt, or thighs? * *

Yes

This field is required

7B. Do you want help to increase your lean muscle mass? * *

Yes

This field is required

7C. Are you allergic to peanuts? * *

Yes

This field is required

8. Do you currently take a daily multivitamin supplement? * *

Yes

This field is required

9. Do you eat 6-12 cups of fresh vegetables daily? * *

Yes

This field is required

10. Are you allergic to soy? * *

Yes

This field is required

11A. Do you want help with appetite control and metabolism? * *

Yes

This field is required

11B. Would you like a healthier alternative to coffee or tea that can also help with weight loss? * *

Yes

This field is required

11C. Would you like a beverage that is full of healthy polyphenols (antioxidants) and has ingredients to decrease weight and body fat? * *

Yes

This field is required