Holistic Health Assessment

Full Name

Birthday

Month

Day

Year

Phone

Email

Address

Provide address to recieve free marketing material and future orders of products

What are your top health goals right now?

Do you have any diagnosed medical conditions?

Are you taking and medications?

Are you taking any supplements?

Any known allergies or sensitivities?

Any past major surgeries, injuries or hospitalizations?

Have you done any testing recently?

How would you describe your energy level?

I wake up feeling refreshed and energized

I have trouble getting out of bed in the morning

My energy crashes mid-morning

I feel a dip in energy in the afternoon (around 2–4 PM)

I rely on caffeine to get through the day

I get a “second wind” at night and struggle to wind down

My energy is steady throughout the day

I feel exhausted no matter how much I sleep

Other

How many hours of sleep do you get per night?

How often do you exercise/move your body?

How would you describe your current stress level?

Low

High

Moderate

Other

Are there any recent life changes, emotional stressors, or events that may be impacting your life?

Do you smoke or vape?

How much alcohol do you consume?

Describe your current eating habits and diet?

Do you experience any GI problems like bloating, constipation, acid reflux, digestive issues?

Females Only: Do you have normal menstrual cycles?

Females Only: Are you on birth control or any hormones?

Females Only: Do you experience PMS or any menstrual cycle abnormalities?

Females Only: Are you pregnant or trying to conceive?

Is there anything else you'd like me to know before we start working together?

I understand that Holistically Trained does not provide medical advice or diagnosis, and all recommendations are educational and wellness-focused.

I consent to be contacted via email for scheduling and follow-up

Review Terms and Waiver: