Tender Shoots Wellness

Date MM / DD / YYYY
Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Cell Phone ### - ### - ####
Gender
Age
Height
Date of Birth MM / DD / YYYY
Place of Birth
Relationship Status
Have any children?
Have any pets?
Occupation:
Number of Hours of work per week:
Current Weight
Weight Six Months Ago
Weight One Year Ago
Would you like your weight to be different?
If so, what?
Do you sleep well?
Do you wake up at night?
What times?
To urinate?
What time do you generally wake up in the morning?
Health Information
Please list your main health concerns:
Other concerns & wellness goals:
Are you experiencing any Constipation, Gas, or Diarrhea?
If so, explain.
Any pain, stiffness, or swelling?
Any allergies or sensitivities?
Any serious illness, hospitalization, or injuries?
What's your blood type?
What is your ancestry?
How is the health or your mother and father?
Ladies only

Nothing personal fellas. You can just skip this section and jump right into "lifestyle stuff".
Are you pregnant?
If so, what's your due date? MM / DD / YYYY
Are your periods regular?
How many days is your flow?
How frequent?

How many days between cycles 28?
Painful or symptomatic?
Please explain
Are you approaching Menopause?
Please explain
Birth Control History
Any history of Yeast Infections or Urinary Tract Infections?
Please explain
Lifestyle Stuff

Here's the fun part! Please be detailed with your answers.
Any supplements or medications
If so, which ones?
Are you involved in any therapy or healing arts? If so, please explain.
How would you describe your level of energy?

How do you generally feel during the course of the day? Skunky, lethargic, jittery...
What role does exercise play in your life?
Do you drink coffee, smoke, or have any major addictions?
Food Stuff

Your intimate relationship with food. Let's talk about it!
What foods do you remember eating as a kid?

List common breakfast, lunch, dinner, and snacks that you ate as a child.
What foods were you eating a year ago?

List common breakfast, lunch, dinner, and snacks that you ate a year ago.
What foods are you eating these days?

List common breakfast, lunch, dinner, and snacks that you are currently enjoying.
Are there any foods you think you should be eating more of?
What foods if any would you like to eliminate from your diet?
Disclaimer: Tender Shoots Wellness health history consultations cannot be construed as a recommendation of medical treatment or medication. These sessions are not professed to replace physical or medical treatment nor is any such claim made. There are no medical recommendations or claims for the any of the vitamin or mineral regimens described in these consultations. Please sign your Full Name below to complete. *
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Tender Shoots Wellness

Health Information

Ladies only

Lifestyle Stuff

Food Stuff

You Did It!