WellnessDaySurvey (#13)

WELLNESS DAY PARTICIPANT INTAKE FORM

Help us make your consultation with Dr. Cherine as impactful as possible by sharing your health background, goals, and daily habits. Your responses will remain confidential

First Name

Last Name

Date Of Birth

1. CHIEF HEALTH CONCERNS & GOALS

2. FAMILY MEDICAL HISTORY

Please complete the following table:

Relation

Health Conditions (tick & specify if applicable)

3. PERSONAL MEDICAL HISTORY

Do you have any chronic conditions? (Please precise)

Do you experience any chronic pain?

Yes

• Frequency & location

• Type of pain

4. NUTRITION & EATING HABITS

• Number of Meals per day

• Water intake

1-2L

>2L

• Protein intake

Sufficient

Insufficient

• Fiber/vegetable intake

Sufficient

Insufficient

• Processed food intake

Frequently

Occasionally

Rarely/Never

• Alcohol

Never

Occasionally

Frequently

• Caffeine

None

1–2 cups/day

>2 cups/day

• Tell us more about your eating habits:

5. PHYSICAL ACTIVITY & MOVEMENT

• Frequency

None

1–2x/week

3–4x/week

>5x/week

• Types of exercise

Cardio

Strength Training

Yoga / Pilates

Other:

• Do you feel exhausted after exercise?

Yes

6. SLEEP & ENERGY

• Sleep time

• Wake-up time

Tell us about any sleep concerns

• Morning energy

Energized

Neutral

Tired

• Afternoon energy (4 PM)

Energized

Neutral

Tired

Nap Required

7. STRESS & MENTAL WELL-BEING

• Stress level

Low

Moderate

High

• How do you cope with stress?

8. RISK FACTORS & BEHAVIORS

Smoking

Never

Former

Current

Former (stopped ___ yrs ago)

How much for how many years?

9. SOCIAL & EMOTIONAL WELL-BEING

• Do you feel supported socially?

Yes

• Are you in a fulfilling relationship?

Yes

• Low mood or sadness?

Yes

• Loss of pleasure in activities?

Yes

10. GUT & DIGESTION

• Bowel movements

Daily

Every 2 days

<2x/week

If you want to elaborate on other factors that affect your bowel movement ( constipation / diarrhea)

11. COGNITIVE & NEUROLOGICAL HEALTH

12. HORMONAL & SEXUAL HEALTH

• Libido

Normal

Low

• Sexual satisfaction

Satisfied

Unsatisfied

• Hormonal symptoms

Women

• Menstrual cycle

Regular

Irregular

• Period pain

Yes

• PMS

Yes

• Are you trying to conceive?

Yes

• Menopause/perimenopause symptoms:

Hot Flashes

Yes

Mood Swings

Yes

Weight Gain around the belly (Abdominal)

Yes

Previous history of hormone stimulation ( IVF) if any

13. FOOD SENSITIVITIES & ALLERGIES

• Known food allergies/sensitivities

Yes

If yes, please specify

Please precise what food allergies you have and tell us about your reaction after eating.

14. IS THERE ANYTHING ELSE YOU’D LIKE TO SHARE WITH US?

Please use the space below to tell us anything you feel is important for Dr. Cherine to know about your health, lifestyle, or goals:

Thank you for sharing. Your responses will help Dr. Cherine personalize your wellness plan and make the most of your 1:1 session.