Essential Apothecaries :: Health and Lifestyle Questionnaire

Book A 15-Minute Wellness Consultation

Health and Lifestyle Questionnaire

Welcome! This questionnaire has been made to make the most of our 15 minutes together and so you are better able to support your own health.

Please note: We are not doctors, and this is not meant to replace your own medical care, or to treat, diagnose or cure any illness.

We are Holistic Health Practitioners, along with other specialized modalities and licensures, however, we cannot provide any medical care or legally give medical advice. We can assist you in having informed conversations with your healthcare practitioner.

We focus on root cause wellness and providing you with your desired outcome in coaching, to align with your personal health goals.

We will refer you back to your primary healthcare practitioner for any medical advice or treatment.

Our promise to you is a commitment to excellence, quality service and compassionate care.

We will help you with the tools, so that you can have the quality of life you desire! Whether you are seeking better nutrition choices, supplementing what you’re already doing, aromatherapy, herbology, custom blending, or needing some educational resources, we are here for you!

Please complete this questionnaire as thoroughly and completely as possible.

All of your information is kept confidential and your privacy is very important to us!

Full Name *

Date of birth *

Email *

Phone *

Gender at Birth *

Male

Female

1: How would you like to do your consultation? *

Zoom

Phone Call

2A: If Other, please explain:

2B: Please provide as much detail about your primary concern as possible: *

2C: Do you have a secondary concern? If yes, please explain:

3: What does your daily dietary intake look like? (Please include regular intake of food choices; Whole foods, grains, any type of meats, processed foods, snacks, sugar intake, etc: You may indicate if you are vegetarian or vegan, etc, however, we are looking for your dietary choices in what you select vs the type of style eater that you are.) *

4: Do you currently take any vitamins, herbal supplements or remedies? *

Yes

4A: If yes, please list what type you take and how often.

Please email pictures of the front label and nutrition/ingredients label of each to support@essentialapothecaries.com.

5A: Other Activities

6: On a scale of 1-10, how would you rate your current stress levels? (Select the drop-down) *

6A: Please add any additional info about your stress level here:

7: How many hours of sleep do you get on average per night? *

8: Do you currently smoke? *

Yes

8A: If you have ever smoked, how long? Also, what age did you start and quit?

9: Do you consume alcohol? *

Yes

9A: If Yes, How many alcoholic beverages do you consume in a week or month?

10: Do you have any medication, food or environmental allergies? (Please list any type of allergies you have and the severity.) *

11: Do you have any addictions? (If you have had addiction to any drugs or alcohol, please use the comment box to indicate which and what type, and how long have you been sober?) *

12: Are you experiencing any depression or anxiety? (Please list details below if applicable. Please also include any current treatment you are under (therapy, medication, etc)) *

13: Do you have any specific health concerns or medical conditions? If yes, please provide details. (Do you have any history of Kidney disease, diabetes, Addison's disease, autoimmune disorders, (lupus, thyroid, chronic fatigue, etc), Crohn’s disease, high blood pressure, brain hemorrhages, aneurism or blood clots, cardiac/cardio vascular disease, heart attacks or stroke? If yes, please disclose any diagnosis of current or past medical conditions such as cancer, asthma, female specific conditions, male specific conditions, brain, epilepsy/seizures, etc. Please include dates of diagnosis and as much medical information as possible.) *

14: Do you currently or have you ever had cancer? If yes, what type of cancer, what location(s), and what is/was your treatment plan? (Include medications, chemo, radiation, holistic, and alternative) (Please include dates of diagnosis and the length of time you have been in remission if that is the case. Please also include the date of any last treatments and the type of treatment it was. The more details helps us see your big picture.) *

15: Do you have any psychiatric conditions such as bipolar disorder, schizophrenia or any other diagnosis? (If yes, please include length of time since diagnosis and any treatment details.) *

16: Are you taking any pharmaceuticals? If so, please list them along with the diagnosis requiring that medication: *

17: Do you use any type of recreational drugs? If yes, please list. (This question also includes any form of cannabis, marijuana, etc. If yes, Please list what one(s), and how often:) *

18: Have you had any of the Covid-19 injections? (If yes, please indicate the following: How many injections you have received? When was your last one? Have you experienced any issues or effects from any of the injections you have received?) *

19: Have you ever had the Covid-19 virus (Any strain)? (If yes, please indicate how many times. Do you have any residual effects from the virus?) *

20: Biological females only: Are you pregnant or trying to become pregnant?

Yes