KETO Adapt For Health
KETO Adapt For Health
with Andrea Walker
CONFIDENTIAL HEALTH HISTORY
Would you like your weight to be different? If so, what?
Relationship Status? Children? Pets?
Occupation? Hours of work per week?
Please list your main health concerns:
Any other concerns and/or goals?
At what point in your life did you feel best?
Do you sleep well? How many hours? Time to bed/time wake up?
Do you wake up at night? If so why? At what time?
How do you feel when you wake up?
Do you have any digestive issues? Please explain:
Do you experience discomfort (gas, bloating, pain, heartburn) after eating? Please explain:
How many bowel movements per day? Any diarrhea or constipation?
Any known food allergies or sensitivities? Please list:
FOR WOMEN ONLY
Age of your first period. Are your periods regular?
How many days in your flow? How frequent?
Do you experience PMS? If so, please describe symptoms:
Brith control history:
How many children have you delivered and how were they born? (c-section /vaginally)
Were there complications associated with these births? If so please explain:
Did you receive antibiotics during labor?
Have you had difficulty conceiving?
Do you experience yeast infections or urinary tract infections? Please explain:
How is your respiratory health?
FOR MEN ONLY
Approximate age of onset of puberty:
Number of children:
Do you feel your libido is adequate? Comments:
Do you wake at night to urinate? How many times per night?
Do you have difficulty and/or pain with urination? DIminished flow or volume?
Do you enjoy daily activities. or do you feel apathetic/complacent about previously enjoyed sports, hobbies, clubs, games, etc?
Do you notice feeling more agitated/irritable than previously?
Do you feel less assertive in daily life than previously?
MEDICAL HISTORY AND CURRENT CARE
Please list any surgeries, accidents, injuries, hospitalizations, or childhood diseases you have had along with the type and the date:
Are you currently under a practitioner's care for a specific health issue?
If so, what treatments are you receiving?
Do you have any issues with your thyroid?
Have you been diagnosed with an autoimmune disorder of any type?
What is your dental history like? Do you have any issues that would cause you to be less able to chew well? Do you have any infections in the mouth?
Please list any vitamins/minerals/herbs/homeopathic remedies, prescription/nonprescription medications, diet pills, or any other supplements. Please list all below including brand names and dosage.
Please list any known allergies to medications or herbs.
What foods did you eat often as a child? Breakfast, lunch, dinner, snacks, beverages?
What's your food like these days? Give a quick snapshot: breakfast, lunch, dinner. snacks, beverages?
What percentage of your food is home cooked? Do you cook?
Where do you get the rest from?
How much water do you drink per day? What type? (tap, bottled, filter, etc.)
Do you drink caffeinated drinks? Which ones, how much, how often?
Do you drink alcoholic drinks? Which ones, how much, how often?
Do you drink soda? (diet or regular?) Which ones, how much, how often?
Do you crave sugar, salt, coffee, cigarettes, alcohol, or have any major addictions?
What role do sports and exercise play in your life?
Describe your weekly exercise routine: Exercise, Intensity, Duration, #times/week
Do you smoke? How much and how often?
If you used to smoke but quit- why, how and when did you quit smoking?
Are you exposed to second-hand smoke? How much and how often?
Have you been exposed to toxic substances at work or home?
Do you have mercury fillings? Do you plan to have them removed?
How is your mother's health?
How is your father's health?
Has a blood related family member of your hd any of the following health conditions? If yes, please indicate if it was their cause of death and specify their relationship to you. Conditions: Alzheiner's, Asthma, Autoimmune disease, Cancer (specify), COPD, Dementia, Diabetes (specify type), Emphysema, Epilepsy, Gall Bladder condition, Glaucoma, Heart attack, Heart condition, High Blood Pressure, Kidney disease, Liver disease, Mental Illness, Migraines, Obesity, Osteoarthritis, Osteoporosis, Parkinson's, Rheumatoid, Stroke, Thyroid condition, Ulcer, Other Medical Condition.
Have you tried addressing your current health concerns in the past? If yes, what happened?
If your body had a message, what is it trying to teach you?
What do you think your body needs in order to heal?
Do you feel you are fully expressing your creativity?
Do you feel like you are living your life's purpose?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you feel ready to make the changes necessary to achieve your health goals?
Anything else you want to share?