Health Backround Assesment

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Health Backround Assesment | Gut Health

Hello dear!

The form below is a quick way to get in touch with your unique function,

by understanding your health backround!

Before our session, i will go through your answers and together we will discuss where the issues lie, set goals for your desired health and wellness

and through holistic practices get you thriving in life!!

Name and Surname *

Age *

Height *

Weight *

Do you smoke? *

Yes

Sometimes/ on and off

How often do you consume alcohol? *

Never

1-2 times per month

3-4 times per month

2-3 times per week

4+ times per week

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

4-6 hours

6-8 hours

8-10 hours

Other:

How does your diet look like? *

Mostly homecooked meals

Mostly pre made food/eating out

A balance between homecooked and eating out

I eat fruit and vegetables every day

I eat fruit and vegetables 3-4 times per week

I eat fruit and vegetables less than 3 times per week

I eat gluten-free

I follow a vegeterian diet

I follow a vegan diet

I follow a keto diet

I usually eat a lot of sugar

I usually don't eat a lot of sugar

I usually eat a lot of salt

I usually don't eat a lot of salt

Other:

Required

Which of the below best describe your avergage bowel movement? *

Going 2-4 times per day

Going once per day

Going once per 2-3 days

Mostly formed stool

Mostly watery stool

Usually a lot of gas

Usually a little gas

Usually no gas at all

Frequent diarrhea

Required

Do you have any food allergies or intolerances? *

Which of these symptoms do you usually get after eating a large meal? *

Sleepiness

Bloating

Reflux

Anxiety

Irritability

Stomach pain

Lower abdomen pain

Other:

Required

Have you ever been diagnosed with a nutriet deficiency? *

Yes

Are you currently taking any dietary supplement(s)?

If yes which one(s)?

How much stress do you have in your daily life? *

A bit of stress but mostly i feel calm

I feel stressed often but it doen't become uncomfortable

I feel stressed almost every day and it gets tiring

I feel very stressed and almost always on tension

Do you have any gut symptoms that show up specifically when you are under stress?

If yes which ones?

Would you say your motivation for self care, socializing and work has been stable in the past 3 months? *

Yes, i have felt motivated

I have had some ups and downs

I have mostly felt unmotivated

Do you take any long term medication(s)? *

Do you have any diagnosed chronic condition? *

Do you have any other chronic symptom, such as pain in a part of your body

or some other symptom that shows up after a specific act,

that causes you discomfort?

What is your assigned gender? *

Female

Male

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