Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
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(###)
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Skype Name
Birth Date
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Age
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Place of Birth
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Height
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Weight
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Gender
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Occupation
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Referred By
Today's Date
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DD
YYYY
Describe Health Related Problems/Symptoms:
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What treatments have you tried?
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Has anything been successful?
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With whom do you live?
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Do you have any pets or farm animals? If yes, where do they live?
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Have you lived or traveled outside of the United States? If so, when and where?
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Have you or your family recently experienced any major life changes? If yes, please comment:
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Have you experienced any major losses in life? If so, please comment:
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How much time have you lost from work or school in the past year?
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Previous jobs:
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Did you feel safe growing up?
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*All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.
Have you been involved in abusive relationships in your life?
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Was Alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
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Do you feel safe, respected and valued in your current relationship?
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Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
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Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues?
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List past Medical and Surgical History:
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List previous hospitalizations:
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How often have you taken antibiotics?
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How often have you taken oral steroids?
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What medications are you taking now?
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*All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.
List all vitamins, minerals, and other nutritional supplements that you are taking now.
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Where you a full term baby? A preemie? Breast-fed or Bottle-fed?
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As a child did you eat a lot of sugar and/or candy?
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What is your typical daily diet:
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How much of the following do you consume each week?
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Are you on a special diet?
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Is there anything special about your diet that we should know?
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Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)?
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*All information provided is for health education purposes only and is not intended to daignose, treat, cure, or prevent any disease.
Do you feel much worse when you eat certain foods?
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Do you feel much better when you eat certain foods?
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Does skipping a meal greatly affect your symptoms?
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Have you ever had a food that you craved or really "binged" on over a period of time?
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Do you have an aversion to certain foods? If yes, what foods?
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How many bowel movements (BM) do you have per day?
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Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?
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Do you have intestinal gas? If so, when.
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How many times per week do you drink alcohol?
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Have you ever used recreational drugs?
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Have you ever used tobacco? (If so, for how long?)
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*All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.
Are you exposed to secondhand smoke regularly?
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Do you have mercury amalgam fillings in your teeth? If so, how many?
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Do you have any artificial joints or implants? If so, which ones.
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Do you feel worse at certain times of the year?
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Have you, to your knowledge, been exposed to toxic metals in your job or at home?
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Do odors affect you? If so, which ones?
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How would you rate your current level of stress?
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Have you ever had psychotherapy or counseling?
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Are you currently, or have you ever been, married?
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List your hobbies and leisure activites:
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Do you exercise regularly? If so, how many times a week?
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What type of exercise is it?
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*All information provided is for health education purposes only n dis not intended to diagnose, treat, cure, or prevent any disease.
Do your parents or siblings have (or had) any health issues? If so, please explain:
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What made you interested in adopting a plant based diet?
Have you ever eaten an all vegan, vegetarian, or pescatarian diet in the past? If so, how long did you eat this way for? Please list which diet you followed and why you no longer eat this way.
What benefits did you experienced during the duration of eating plant based?
Did you experience any negative side effects or struggles while eating plant based? If so please explain.
What are your favorite meals to eat (vegan and none vegan)?
What are your favorite snacks (vegan and none vegan)?
What do you think might be challenging for you on a plant based diet?
Have you had your vitamin levels such as B12 and vitamin D3 checked in the past year?
Are you interested in the health and research that proves a plant based diet is the healthiest for longevity and optimal health? If so would you like me to send you some links of resources and facts providing this data?
Why do you believe you would be a good candidate to work with Ashley Alex Wellness?
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Please add any other information you feel is important:
Congratulations, you are on the path to taking your first step towards health and wellness!
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