This form helps us understand your biology before your first session. Answer with clarity and honesty.
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Please fill the following
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Please enter your mailing address
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What is your birth date?
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Are you currently under the care of a doctor?
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What is the reason?
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Have you ever been diagnosed with any of the following? (Even in childhood) Check all that apply.
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What symptoms are you currently experiencing? (Check all that apply)
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Have you ever had any digestion issues?
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Please describe any reaction or food
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Have you been hospitalized?
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What was the cause of your hospitalization?
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Are you taking any medications right now?
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Which medications are you taking?
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Do you take any supplements?
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Which supplements are you taking?
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Have you ever had a strange reaction to medication or supplements?
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Please describe any reaction or to what you had a reaction to
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Lifestyle Snapshot
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List any allergies (food, environmental, animal, etc). Describe any allergy in detail
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Lifestyle Snapshot
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Describe your current diet
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Lifestyle Snapshot
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How many hours of sleep do you get?
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Do you take anything for sleep?
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What do you take?
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Lifestyle Snapshot
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Do you track sleep or biometrics? (Which device?)
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Have you ever used a Continual Glucose Monitor or any blood sugar measurment?
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Are you open to using one?
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Measuring blood sugar is more than just how your body responds to sugar or carbs. Some people are more sensitive to higher amounts of protein or fats. It also tells us how you respond to stress, your environment and people. We can also tell how fast your body recovers.
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Lifestyle Snapshot
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What is your typical daily energy level? (1–10 scale) Does it slump during the day?
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Lifestyle Snapshot
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How often do you move or exercise per week? Please describe your workout routine.
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Do you currently or have you ever used any tobacco or nicotine products?
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If yes, please describe
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Do you drink alcohol?
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If yes, specify what type, how much and how often per week/month.
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Do you take any drugs
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There is no judgment. If the answer is yes, when I am choosing therapies, this helps me avoid any interactions in the pathways of your body.
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Please list any drugs you take, how you take them, the amount you take and how often.
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Do you have regular dental care done?
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Please list regularity, any current dental issues and/or any dental procedures you have done
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Please check any therapies you have done
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What are your top three goals?
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The most important should go in the #1 spot. 1. 2. 3.
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If there was one thing you could wave a magic wand and change, what would it be?
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What does vitality, good health and feeling good look like to you?
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What are your expectations over the next 3 months working with Kelly?
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Is there anything you want Kelly to know?
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If you have not sent us your labs, upload any recent labs (bloodwork, DNA, hormone panels, etc)