Lifestyle Assessment Form
Peak Performance Wellness Center
Email address *
Name *
Your answer
Phone *
Your answer
Birthdate *
MM
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DD
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YYYY
If you have a diagnosis or core issue you would like to work on list it below.
Your answer
List the primary symptom that goes with your diagnosis or core issue. Include when it started, which organ(s) is involved and what was going on in your life around the time it started.
Your answer
If you have a secondary symptom you would like to focus on list it below. Include when it started, which organ(s) is involved and what was going on in your life around the time it started.
Your answer
If you have additional symptoms you want to work on in future appointments, please list them below. Include the date they started, organ(s) involved, what was going on in your life around the time they started etc.
Your answer
List traumatic or shocking events throughout your lifetime and appropriate dates.
Your answer
If you take prescription medications, list each below along with how long you have taken each.
Your answer
If you take supplements, list them below.
Your answer
List any surgeries you have had.
Your answer
How many ounces of water do you drink each day? *
Your answer
What kind of water do you drink? *
Required
How much sweaty activity do you participate in weekly? *
Your answer
What type of sweaty activity? *
Your answer
How many bowel movements do you have each day? *
Your answer
Do you take Probiotics? *
Do you take Digestive Enzymes? *
Which meals do you eat each day? *
Required
What are your favorite foods? *
Your answer
What type of foods do you crave? *
Required
How often do you eat out? *
Your answer
How many alcoholic beverages do you consume each week? *
Your answer
Do you smoke? *
Which of these do you consume? *
Required
List everything you had to drink/eat yesterday. *
Your answer
What time do you go to bed? *
Time
:
What time do you wake up in the morning? *
Time
:
How is your energy level? *
non existent
extremely good
Do you feel stressed? *
Your answer
How many hours a week do you spend with family and friends? *
Your answer
How much time do you spend outside each week? *
Your answer
Please list any family health history that you feel would be good for me to know. *
Your answer
Do you have a pacemaker or other electronic implanted device? *
What would you like to focus on during your 1-1 consultation? *
Your answer
Is there anything I have not asked about that you would like for me to know? *
Your answer
Details for Your Appointment
To prepare for the scan that will take place during your appointment, please follow these guidelines:
Drink 8 ounces of water throughout the hour before your appointment.
Stop supplements 24 hours before appt. Continue prescription drugs.
No alcohol or caffeine 12 hours before your appointment.
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