Peak Wellness Lifestyle Assessment Form 2022

First Name *

Last Name *

Phone Number *

Email Address *

Birthday (mo/day/year) *

If you have a diagnosis or core issue you would like to work on list it below. *

List the primary symptom that goes with your diagnosis or core issue. *

List traumatic or shocking events throughout your lifetime and appropriate dates. *

How would you describe yourself? You can include strengths and weaknesses. *

If you take prescription medications, list each below along with how long you have taken each. *

If you take supplements, list them below. *

List any surgeries you have had. *

How many ounces of water do you drink each day? * *

How much sweaty activity do you participate in weekly? *

How many alcoholic beverages do you consume each week? *

Do you smoke? *

Yes

What time do you go to bed? *

What time do you wake up in the morning? *

How is your energy level? *

How much time do you spend outside each week? *

Please list any family health history that you feel would be good for me to know. *

What do you believe your body needs to be able to heal? *

What are 2-4 emotions you experience daily? *

Do you have a pacemaker or other electronic implanted device? *

Yes

What would you like to focus on during your 1-1 consultation? *

Is there anything I have not asked about that you would like for me to know? *