Gut Health Consultation Intake

Please complete this intake upon scheduling your appointment. Your GI MAP test will not be ordered until this is submitted.

First name

Last name

Email

Address (Please write full address so we can mail your testing kit. )

Phone

Date of birth

Month

Day

Year

Occupation

Gender

Female

Male

Anthropometrics

Height

Current weight

Medical History

Please list any prescription or non prescription medications you use regularly with name and dose (example: Vitamin D3, 2000 iu daily)

List any known food or drug allergies (including herbs/supplements)

Surgeries, accidents, major injuries and hospitalizations and when they happened

Are you currently under the care of any health care providers for any medical conditions? If so, please explain.

Have you had frequent illnesses in the past requiring antibiotics?

Yes

No

Do you have a history of kidney disease?

What are your main health concerns?

Sleep, Stress & Energy

How many hours of sleep do you get on average?

Do you feel rested when you wake up in the mornings?

Yes

No

Sometimes

What time do you usually go to sleep and wake up?

Do you struggle with falling asleep and/ staying asleep? If so which one?

Describe your energy pattern throughout the day (Example: wake up wired, get really tired at 3 pm)

How would you rate your stress level in life right now? (1=Low, 10=Extreme)

How would you rate your ability to handle your stress? (1=Low, 10=Extreme)

Do you experience discomfort (pain, gas, bloating, heartburn, nausea) after eating? Please explain:

How often do you have a bowel movement and what number on the Bristol scale are your BM's usually?

Are there any foods that give you undesirable symptoms? Please list them out.

Female Health

Age of your first period?

Are you pregnant? If so, when is due date?

Are your periods currently regular? Was there a time in your life where they were irregular? Please explain

How many days does your period last? How many days are your monthly cycle (first day of your period to the first day of your next period)?

Birth control history (What you were on in the past and if you're currently still taking anything)

Are you in menopause? If so, how old were you at the onset?

Do you experience frequent yeast infections or urinary tract infections? Please explain any trends or patterns you have noticed (ie yeast infection right before your period starts, frequent UTI's after sexual intercourse)

Nutrition

Have you ever been formally diagnosed with an eating disorder?

Yes

No

How many times per week do you eat out?

*Please specify any other specific dietary requirements/restrictions

How many times do you usually eat each day?

How many ounces of water intake do you average daily?

How much caffeine do you drink daily on average?

Do you have any intense cravings or addictions? (i.e sweets, alcohol, cigarettes, greasy foods, bread, coffee etc. )

Occupational Health

What would you consider your current weekly exercise routine?

No current exercise routine

1-3 hours gentle exercise (walking)

3-4 hours moderate exercise (running, exercise classes, Peloton)

4-6 hours intense exercise ( crossfit, weightlifting)

How many alcoholic beverages do you have per week on average? (Be honest, no judgement here!)

Have you had any toxic exposures that you are aware of? (heavy metals, extreme pollutants, working with radioactive material etc.) Example: Do you spray your yard with weed killer?

Anything else you want to share?

CONTACT

Sophrosyne

Health