Client Health Questionnaire

Food Intolerance

Please complete this form before your appointment to help us personalize your session.

Full Name

Date of Birth

Phone Number

Session Date

What are your main health concerns or symptoms? (Such as Bloating, Gas, Stomach pain, Acid reflux/heartburn, Constipation, Diarrhea, Fatigue/low energy, Skin issues (eczema, acne, rashes), Joint pain/inflammation, Headaches/migraines, Anxiety/stress, Sleep disturbances, Weight gain/difficulty losing weight, Brain fog/difficulty concentrating, Frequent colds or immune issues, Other)

Do you have any known allergies? (If yes, please list)

Have you been diagnosed with any food intolerances? (if yes, please list)

Do you suspect you might have a food intolerance? (If yes, please list the food that may be an issue)

Have you noticed any foods that cause discomfort or symptoms? (If yes, please list)

How often do you experience digestive discomfort?

Are you currently following any specific diet or eating plan? If yes, which one?

Do you regularly consume:

How would you rate your stress levels?

How would you rate your sleep quality?

How often do you exercise?

Do you have any diagnosed health conditions? (e.g., IBS, thyroid issues, diabetes, autoimmune disorders). If yes, please list.

Are you currently taking any medications or supplements? (Please list)

Have you had any recent blood work or medical tests done? (If yes, please specify.)

What do you hope to achieve from this food intolerance session?

Do you have any other concerns or relevant information?

I understand that this food intolerance session is for informational purposes only and does not serve as a medical diagnosis. I acknowledge that any dietary changes I choose to make based on this session are my responsibility.