Gut Reset - Intake Form
This form is to provide me with an understanding of your health history, before we start working together.

Please fill out this form as accurately and detailed as possible. I will contact you within three business days of submitting this form to book our initial consultation.

*Please note that this service is currently only available to Canadian residents. 
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First and last name *
Email address *
Date of birth *
Gender *
How did you hear about me? *
Height (cm) *
Weight (lbs) *
Do you have any known allergies? If yes, please list.
 *
In order of priority, list 1-3 health concerns. How long have you been experiencing these symptoms or concerns? *
What do you believe or suspect are the reasons you are experiencing these symptoms or concerns? 
 *
In which ways have you previously tried to address these concerns or symptoms? Have you worked with a doctor or another practitioner before? *
Are you currently being treated for any medical issues? If yes, please explain.  *
List all surgeries you have undergone throughout your lifetime. Please include your age or the year the surgery was performed. 

(i.e., wisdom teeth removal at age 15, appendix removal at age 23, etc.)
 *
List all medications you are currently taking or have taken in the previous 12 months.  *
Please list all supplements (both vitamin and herbal) you are currently taking.  *
Depending on the protocol I will design for you, herbs and supplements may be included. Are you comfortable using capsules, tinctures, and teas?  *
List any illness or health issue you have suffered from or are currently living with. Include the age you were when dealing with listed illness. 

(i.e., cervical cancer at age 30, kidney stones at age 42)
 *
What physical, emotional, or mental trauma have you experienced?

(i.e., car accident, abusive partner, death of a loved one)
 *
List stressful events throughout your lifetime. 

(i.e., moving several times, declared bankruptcy, living with a partner who suffers from PTSD, physical stress due to surgeries, etc.)
 *
If applicable, what do you do to manage / relieve your stress?
How many bowel movements do you have per day? By referring to the Bristol Stool Chart, please indicate which type(s) best represents the shape and form of your stools. 
 *
Describe your dental history. Please list the number of cavities or amalgams, root canals, bridges, etc. 
 *
Menstrual health questions - if you are a male, please input "N/A". 

1. Do you remember at what age you had your first menses? 
2. What symptoms do you experience during your period (breast tenderness, cramps, irritability, mood swings, etc.)? 
3. What is the length of your cycle (28 days, 30 days, 35 days, etc.)?
 *
Women's health question - if you are a male, please input "N/A". 

Are you currently, or have taken hormonal birth control? If yes, please list the type of birth control, the brand (if possible), and the number of years taking this medication.

(i.e., birth control pill for 12 years, stopped taking 3 years ago, not sure of the brand)
 *
List any known health conditions of your biological parents.

(i.e., father has type 2 diabetes and suffered of a heart attack at the age of 40 ; mother is healthy with no known health conditions or issues)
 *
Do you have any siblings? If yes, please list any known health conditions. If you do not have siblings, input "N/A".
 *
Are you a cigarette smoker? Or, did you smoke in the past? If yes, how many years? When did you quit? If no, input "N/A"
 *
How often do you consume alcohol?
 *
What is your daily consumption of:
- Water
- Carbonated water
- Green tea
- Black tea
- Herbal tea
- Coffee
- Fruit juice
- Soda
- Dairy products (milk, cheese, cream, yogurt, etc.)
- Sugar 
 *
What is your current occupation?
 *
Please give a rough estimate of how much blue light you are exposed to on a daily basis (cellphone, television, computer).
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What is your average bedtime?
 *
What is your average wake-up time? 
 *
Is there anything that will stand in your way of putting your health first? *
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