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Personal Health Assessment Form

Congratulations on taking the next step to transform your life for the better. This questionnaire is to give me have a better understanding of your unique needs so I can design your own personal care plan. I want to thank you for allowing me to partner with you creating a life filled with more love and happiness.  



*Note: Please feel free to skip any questions you are uncomfortable with. 


Pronouns (if used)

Email Address*



City/State/ Zip Code

Date of Birth / Age

Current weight and height

Emergency contact and phone number

What is the primary situation causing you the most amount of stress?

What would you like to change about your current situation?

Are you currently pregnant?

If you are pregnant, what is your due date?

Number of Pregnancies?

Number of living children?

Number of miscarriages?

Number of vaginal births?

Number of C-setions?

Did you have any difficulty conceiving in the past?

If so, explain.

Have you tried ART (artificial reproductive technologies)?

Have you ever experienced any traumatic events?

Have you ever experienced domestic violence?

Do you have chronic pain?

If so, where? How do you manage the pain?

Are you currently under the care of a physician?

Please list the name of your current OB/Gyne and PCP and telephone number.

Are you currently working with a Doula?

If so, who and their contact number?

List any diagnosis you currently have.

List any allergies and sensitivities.

List any vitamins and supplements you are currently taking.

List any medications you are currently taking and why.

What are the stress reduction techniques you have used or are currently using?

Are you using any recreational drugs?

If currently using any recreational drugs, please list and how often?

How often do you drink alcohol?

Do you smoke cigarettes?

Have you ever been treated for substance abuse?

Have you ever been diagnosed with an eating disorder?

Have you ever been diagnosed with a concussion?

On average, how many hours a night do you sleep?

Do you wake feeling rested?

Do you work shift work?

Do you take anything at night to help you sleep?

How much water do you drink daily?

How often do you consume caffeine? Check all that apply.

How often do you consume sweets, cakes, chips, cookies, ect.

How often do you eat at fast food resturants?

How many meals do you eat daily?

What foods do you crave under stress? Check all that apply.

How often do you exercise?

What type of exercise do you like to do?

What is your religion?

On the following questions please rate how happy you are in each of the areas. The scale is 0-5. O being very dissatisfied and unhappy. 5 being very happy and content.

Your life in general

Your physical health

Your energy level

Your weight

Your financial health

Your social life

Your career

Your relationship with your mother

Your relationship with your father

Your partner

Your sex life

Your personal time

The quality of your sleep

Your mood

Your self-confidence

Select the words that describe your symptoms when stressed. Select all that apply.

List your weaknesses

List your strengths

Describe if anything was possible, in the next few years, what would you want your life to look like.

Based on the life you described above, rate your belief on how well you can see it happening. 0 - is you can not imagine it. 5 - is you can see it becoming a reality.

Please list any other comments or concerns.

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